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�8 &] |M �MDK�j <br /> � ����Y�}WU�lWW�/v Environmental Health <br /> ---�,8UNTY^-- ' ' -- Department <br /> ~ <br /> Greatness grows here- <br /> Monitoring UV8U/S{)'| BO['Dg >nSOeCƒ'OUA8DO[f <br /> ` k1/ <br /> Date:�������� Inspector, CONSTRUCTION <br /> Facility Address: C'wll'qt� <br /> Well Address: Total Depth: <br /> vv DhUin8K�Type: <br /> Soil - Min 2"Annular EHDSea]Verified: [] Yes []No <br /> - Screen From� To: <br /> D/x= Onsite: `-------_-- <br /> Consultant: Filter Pack From� To:- <br /> Geologist: Bentonite From� To:__________ <br /> Grout From: To:__________ <br /> Public Water System Onsite' [] Yes []No <br /> � C{DVUqJBD{}N ElStove Pipe []ChristieBox <br /> Domestic Well Onsite: [] Yes []No <br /> caa±ng <br /> |fyes, location and distance: uu±sut <br /> l/UVUqJNG <br /> Holding Temperature: couvLF-vom <br /> &Yethod: smUuuem�= <br /> Screening Method' <br /> Verified Chain ofCustody: [] Yes []No <br /> SPOILS <br /> ^ <br /> Contamination Noted: El Yes []No <br /> |fyes,spoils storage Location: <br /> Covered: [] Yes []NoPack <br /> Ifyes, material: <br /> GROUTING or DESTRUCTION / <br /> Total Depth ' <br /> Depth toWater: _____o' <br /> Grout Material: <br /> Gallons ofGrout Used: <br /> Casing Type: <br /> []VVeU Installation []VVe| Destruction Blank Feet Screen Feet <br /> []Boring Installation M8ohngDestruction Slot Size: <br /> Bags ofCement: <br /> METHOD USED BaBsSand/Grave|: <br /> Type/BnandofBenton�e� <br /> OP��umGmutOOverDhU <br /> Filter Pack Type/Iize: <br /> [] Gravity 17�[Trehnie []Other: � Type of Method: <br /> Water Cement 471b Water Cement 94 1 b <br /> —gallons Bags gallons Bags <br /> Thickest Thinnest Bags Thickest Thinnest Bags Bentonite/Cement Mix 31/1. Mix 50/. Mix <br /> 2.5 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94 11b 2.82 4.7 <br /> 15 30 30_ <br /> 1-115 35 7 35 70 7 <br /> 1O/16/Z017 <br /> 18GOE. Hazelton Avenue I Stnoko"n. California S52O5T 209468-34201 F 209 464-0138 1 <br />