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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> Site Address x,515 tjo-VI qr, ,,A'-Date )x 3-ea <br /> Job Number tp,2o5- I•,e� p Technician lye Page--!—of 5 <br /> $ x b Well Not Previous) <br /> Now Y <br /> v 'gpp m g v Inspecie0 Defide Itlentified Notes <br /> $m E'3 m m ix (explain In Deficlen <br /> J, 3 cg (e 3 L0 ndes) <br /> Identified Persists <br /> Well ID <br /> v,•L �/ <br /> w-{a <br /> { <br /> -lD <br /> w-( <br /> w i <br /> Mtti-�' 7c <br /> t-- - <br /> I' y <br /> st <br /> 'Well box mumeet 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 /> BLAINE TECH SERVICES,INC. SANJOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE www, I <br /> tMa rretern.can <br />