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e��'�` �& � '���&�U|N <br /> J�����Q�4WW�yV <br /> i —COUNTY— Environmental Health Department <br /> �regoe^, gmv, here <br /> MOD'tOr'Dg VVeU /SO'| Boring |D5OeCf'OO ReDO[f <br /> Dace:—~ _e�_� CONSTRUCTION ' <br /> Facility Address: <br /> Well Address: Total Depth: 3^V-04 <br /> vv ex*r DhUin8RigType. <br /> Soi| 8ohng#: <br /> yWin 2"Annular EHDSeal Ver�ed' FYes []No <br /> Drilling Company: nq ��.��� ' <br /> Driller Onsite: ~ °/ Screen Length From z- To�_�2er&____ <br /> Consultant: ^ Filter Pack From:_Po4To <br /> Geologist: Bentonite From: 0To <br /> Grout - From: To:_________. <br /> Public Water System Onsite: []Yes []No <br /> {�}&V9UETl{DN [] Stove Pipe [][hristip8ox <br /> Domestic Well Onsite: [] Yes []No <br /> cu=J_ns <br /> |fyes, location and distance: � ' height <br /> SAMPLINGAB0VF <br /> Holding Temperature: co&��T�NCOMPLETiON <br /> – ' <br /> Method: s=nmoual=° <br /> Screening Method: <br /> Verified Chain ofCustody: [] Yes []No <br /> SPOILS ^^ <br /> Contamination Noted: [] Yes []No <br /> |fyes,spoils storage Location: } <br /> omuvd 15 <br /> Covered: [] Yes []No – | <br /> Ifyes, material:GROUTING or DESTRUCTION ^--'-- <br /> Tot | Depth: ________ <br /> Depth toWater: —n' 'r <br /> Grout Material: <br /> Gallons ofGrout Used: � <br /> Casing Type: 5�'�I-P –4^P <br /> LJVVe|| Installation []VVe|| Destruction Blank Feet Screen Feet <br /> � <br /> []Boring|nsta||ation []8oringDestruction Slot Size' <br /> Bags ufCement: <br /> METHOD USED Bags Sand/Gravel: <br /> � <br /> []PressureGrout []OverDri|| Type/Brand ofBentonite� <br /> Filter Pack Type/Size: <br /> [] Gravity []Tremie ' []Other: Type of Method: <br /> Water Cement 47 1 b Water Cement 94 1b <br /> aallons Bags allons Bags <br /> Thfckest Thinnest Bags Thickest Thinnest Bags BentoniteXement Mix 30 Mix 5% Mix <br /> fiall,t,enr, <br /> Thinnest <br /> 5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 <br /> 10 20 4 20 40 4 <br /> Y�'`|\*~� <br /> is 30 6 30 60 6 — ^ �wt���� °4-jjj7 35 70 7 <br /> 20 40 8 40 80 8 <br /> C*°0%^°1 » wm� �,��� �� �m� ` � <br /> 1�"�� ~ ' '– <br /> _��---- *«� , � <br /> 1U/16/ZO17 <br /> 1888 E. Hazelton Avenue I ShocNbn, California 95205 1 T 209 468-3420 F 209 464-0138 1 <br /> –7Z <br />