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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> Site Address 36 15 n ary , Sfocjc vD <br /> Date 9- 7-9' <br /> Job Number //p q 07 . 0-41 Technician Joe- La x S <br /> Page - of 3 <br /> 'L o E --------__ <br /> $ c Y� o tL x ,� Well Nol P Wousl <br /> v ' m E$ a b Ins ec(etl Flew 2 Y <br /> v m E N m °' ¢ ¢ p DeAclency Identified <br /> _ o 'Q u s+ (exptain In Ooflcienc <br /> t °i U v to u m notes Identified Notes <br /> Well ID Persists <br /> Mw- 19 <br /> M, w ;�d O a <br /> � w-2-3 K <br /> rviw-�4 x <br /> ,tet w- 3 C3 X <br /> Aw- 3z X <br /> ,--I w.-3j X <br /> M w.- 3,9 <br /> "Well box must meet all three criteria to be compliant:1)WELL IS SECURABLE BY DESIGN(12"dr less) 2)WELL IS RKED WITH THE WORDS <br /> "MONITORING WELL" (12"Or less) 3)WELL TAG IS PRESENT,SECURE,AND CORRECT <br /> Notes: <br /> dt A1NE TECH SERVICES.INC. <br /> SAN JOSE SACRAMENTO LOS ANGELES <br /> SAN DIEGO SEATTLE wviw.olainelecn wm <br />