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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> Site Address {S ,vary , StocFt €a <br /> Date q- 7-11 <br /> Job Number flo?o7 . sL 9 Technician Joe. l OwL50 Page 3 of <br /> Z o E <br /> 8i ¢ v o u' x & Well Not <br /> m 2 m E o y o `—° 0 New Previously <br /> a s p� o n a Inspected Identified <br /> �' v m° E m m °i ez lain in Defriency <br /> I p Itlenlifled Deficiency Notes <br /> Well ID <br /> no, <br /> Persists <br /> a <br /> x <br /> ��- 3j X <br /> pw-�- x <br /> 'Well box must meet all three criteria to be compilant; 1)WELL IS SECURABLE BY DESIGN(12"or less) <br /> "MONITORING WELL" (12"or less) 3)WELL TAG IS PRESENT,SECURE,AND CORRECT 2}WELL IS MARKED WITH THE WORDS <br /> Notes: <br /> BIAINE TECH SERVICES,INC. SAN JOSE SACfiAMENTO LOS ANGELES <br /> SAN DIEGO SEATTLE \r\vN.plainelaCnA.CWn <br />