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_'°��ry ` 5AN 1UA(�UIN <br />��''r����` COUNTY <br />,'� ' �;_ <br />`:°q�;F�; Greatness grcws here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: �-1��2.��Z Inspector: ��� CONSTRUCTION <br />Facility Address: )� %.���-�-� <br />Well Addre <br />WP# ��� g Well#: <br />�� <br />Soil Boring#: �% � �� <br />Drilling Company: ��l�.ccri- �- <br />Driller Onsite: <br />Consultant <br />Geologist: <br />Public Water System Onsite: <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />Verified Chain of Custody: ❑Yes ❑No <br />SPOILS <br />Contamination Noted: ❑Yes ❑No <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />❑ Yes ❑ No <br />�'�3 � <br />��3 <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑Yes ❑No <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION <br />j ._. <br />❑ Stove Pipe <br />casing <br />height <br />❑Christie Box <br />- - - - �- :. <br />.. <br />.. <br />r\ `u � <br />ft <br />i <br />�3 <br />GROUTING or DESTRUCTION Total Depth: C%/��� r <br />Depth to Water: <br />Grout Material: �/�'� �:� <br />Gallons of Grout Used: 3 � � � S1lJ,c�� <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation I�Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑ ver Drill <br />❑ Gravity remie ❑Other: <br />water- <br />allons <br />Cement 471b <br />Bas <br />S°.�o Mix <br />Water <br />allons <br />Cement 941b <br />Ba s <br />Thickest <br />Thinnest <br />#Bags <br />2.82 <br />Thickest <br />Thinnest <br />#Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />__ <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />Ha�Pltnn <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 <br />8 <br />.! <br />� <br />3afo Mix <br />S°.�o Mix <br />E3entonite per 4l Ib <br />1.41 <br />2.47 <br />E�entonite <br />per 94 Ib <br />2.82 <br />4.7 <br />,: <br />__ <br />� <br />a •'. <br />= <br />1 <br />RFR <br />F <br />Ha�Pltnn <br />AVAnI rP I <br />. <br />�alifnrnia <br />q-r,�(l.ri <br />I <br />T �(l9 <br />- <br />W `1.�.� <br />Y i <br />�� <br />saC,ion <br />��'� <br />- <br />4�4-r71 <br />�R <br />I www �i�Ph�l <br />rnm <br />�f <br />::Y.. <br />.�. <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />rl <br />Screen <br />ft. <br />Feet <br />BentonitelOement Mix <br />3afo Mix <br />S°.�o Mix <br />E3entonite per 4l Ib <br />1.41 <br />2.47 <br />E�entonite <br />per 94 Ib <br />2.82 <br />4.7 <br />10/16/2017 <br />1 <br />RFR <br />F <br />Ha�Pltnn <br />AVAnI rP I <br />Stnnktnn <br />�alifnrnia <br />q-r,�(l.ri <br />I <br />T �(l9 <br />4�R-�4�(l <br />I F �C19 <br />4�4-r71 <br />�R <br />I www �i�Ph�l <br />rnm <br />