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r <br /> SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> Site Address i�5t5 Rloot,it Dr. SAooKioh cj�' Date oa-3-m <br /> Job Number IDm2,z Technician H Page .2, of _ <br /> 0 <br /> ; LL <br /> m Well Not Prevlousl <br /> a 8 Inspected New Identified <br /> ._ a $,�' m a = m m DeficiencyNotes <br /> m E m rc mm (explain InDeficiency <br /> V ¢ 3 U 3 notes) Identified Persists <br /> Well ID <br /> �Nw I JIX t�v I <br /> Yt� -Ao <br /> w- ai <br /> nw•2L <br /> w�5 <br /> � b X <br /> ,N- n <br /> Mw. yy <br /> *Well box must meet all three criteria to be compliant:1)WELL IS SECURABLE BY DESIGN(12"or less) 2)WELL IS MARKED WITH THE WORDS <br /> "MONITORING WELL" (12"or less) 3)WELL TAG IS PRESENT,SECURE,AND CORRECT <br /> Notes: <br /> SLAINE TECH SERVICES,INC. SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE xww.LtlalneteGf.Com <br />