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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> Site Address 351 Ncw, Dr - �' _Date a 2 3 -to <br /> Job Number n Technician_ ¢�F Page of <br /> Z a H e <br /> A7 h `m o u" x W Well Not Previously <br /> '3 x a 2 m $ u �- Inspected New Identified <br /> �i CS E m x (explalnin Deficiency Deficiency Notes <br /> o 0 c. identified <br /> Well ID <br /> 3 v notes) Persists <br /> -127 )K <br /> w•.'�.. .:-lz �o L <br /> `Well box must meet all three criteria to be compllant:1)WELL IS SECURABLE BY DESIGN(12"or less) 2)WELL IS MARKED WITH THE WORDS <br /> "MONITORING WELL" (tYbr less) 3)WELL TAG IS PRESENT,SECURE,AND CORRECT <br /> Notes: <br /> ELAINE TECH SERVICES.INC. SAN JOSE SACRAMENTO <br /> LOS ANGELES SAN DIEGO SEATTLE wxw.tYeinetegtccm <br />