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�� k[ |�K0U/N <br /> ^� ��A���UW�f�U�f� —0nfir0Kto—rieKtmKHealth D_�~paCh00err* <br /> � ( 0UNTY _ <br /> Gr umeo y <br /> grows �e,s <br /> MOD't0['DgVU8U/c(}'| AO['Dg |nSpeCf'OD AeOO[t <br /> Date Inspector: <br /> Facility Address:(oOit Rnp .6k. <br /> Well Address: Tota| Depth:_______ <br /> "^ Drilling Rig Type: <br /> ��inZ"Annular EHDSeal V���ad: []Yea []No <br /> || Screen prom� To: <br /> Driller <br /> Cons Filter Pack Fnom:— To: <br /> `---------' <br /> Geologist: Benton�e Fnom� To:_______�__ <br /> ` <br /> Grout From: To' <br /> �— <br /> Public Water System Onsite�� [] Yes []Nu <br /> COMPLETION [] Stovepipe [][hristieBox <br /> Domestic Well Onsite: [] Yes []No <br /> =using. <br /> |fyes, location and distance: height ' <br /> Su&NqJNG <br /> Holding Temperature: \cow L—_j�ON- ' <br /> Method' <br /> Screening Method: <br /> � grout . <br /> Verified Chain ofCustody: 11 Yes ONo <br /> SPOILS ^^ <br /> Contamination Noted: []Yes []No <br /> If yes,spoils storage Location: � <br /> Covered: [] Yes []No --'—n ] <br /> |fyes, material: <br /> GROUTING or DESTRUCTION Total Depth: _itO -1�k | <br /> � <br /> Depth toWater: <br /> GroutMateria|: <br /> Gallons ofGrout Used: <br /> CasingType: <br /> L]VVe|| /nsta||ation []VVe|| Detruction Blank Feet Screen Feet <br /> Slot Size: <br /> []8ohng/n�aUation ��Bohn�De�truotion ' <br /> -r Bags ufCement: <br /> METHOD USED BagsSand/Srave/: <br /> Ty�e/Brandof8enton�e' <br /> []PressureGrout []OverDriU � <br /> Filter Pack Type/Size: <br /> [] Gravity )CTnemie []Other: Type of Method: <br /> Water Cement 471b m ent 94 lb <br /> gallons Bags <br /> Thickest Thinnest '18ags Thi kest Thinnest 11 Bags Bentonite/Cement Mix 3% Mix 5% hqix <br /> 2.5 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 <br /> 12.5 15 25 50 5 <br /> ' <br /> 20 40 80 8 <br /> 1O/16/ZU17 <br />