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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> Site Address 36 15 navy , S>tnckfo, Date q-7-ft <br /> Job Number /10407 - 6r <br /> E19 Technician -2, L41,, Page —L-0f <br /> 8 <br /> Well Not Previously <br /> g ? X o. m .8__' B m Inspecled Oen Identified <br /> m m E 5 m m m m (explain in Acy Deficiency, Notes <br /> c <br /> m <br /> 3 v y '� notes) <br /> Well ID Identified pencists <br /> y 0. <br /> Mw- 3 x <br /> M W-t1 <br /> m / <br /> /%iW-7 x <br /> rt w" 9 <br /> rlW^ rt R SrA <br /> rs w- ia. X <br /> tq <br /> ~4 4 5 <br /> 16 <br /> 17 M w- 17 <br /> 'Well box must meet all three criterfa to be compliant:1)WELL IS SECURABLE BY DESIGN(12"or less 2)WELL IS MARKED WITH THE WORDS <br /> "MONITORING WELL" (12br less) 3)WELL TAG IS PRESENT,SECURE,AND CORRECT <br /> Notes: <br /> ELAINE TECH SERVICES,INC. SAN JOSE SACRAMENTO LOSANGELES SAN DIEGO SEATTLE vrew. <br /> elainelecn.cmn <br />