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SAI; 0, 11I�rj­ <br /> (Z 0 U NI T Y------- z "N"t; J� L <br /> IV oniltodng Well/Soil Bcl.ring InspeCticon R e p ci rt <br /> Date: Inspector: CUP .:OUUST RUCTION <br /> Facility Address: k-Mixel A* <br /> Well I I Address: Total Depth: <br /> W P#00M Owl.- —Well Drilling Rig Type: <br /> Soil Borillg#: I <br /> Drilling Company: CEO Mill 2"Annular END Seal Verified: 11 Yes ONo Driller Onsile: KM L109exti Screen Length Rola:rn To: <br /> Consultant: Filter Pack From: To: <br /> Geologist: Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: 1:1 Yes ONo COMPLETION El Stove Pipe ElChristie Box <br /> Domestic Well Onsite: 0 Yes EINo <br /> 11 yes, location and distance: <br /> SAMPLING <br /> Holding Temperature: <br /> Method: <br /> Screening Method: 61i �rec <br /> rM <br /> Verified Chain Of Custody: 1:1 Yes ONO <H <br /> PEI <br /> SPOILS <br /> E <br /> Contamination Noted: D Yes ED No <br /> If y,---s,,spoils storage Location: <br /> 119,F <br /> Covered: 0 Yes ONo <br /> 1'F yes, material: <br /> GROUTINIGoi-DES TRUCTION Total Depth: <br /> Depth to Water: <br /> Grout Material: FIR40 CEMIK*I-' !'AiATERIALS A EVE:DOP N11OF1 <br /> Gallons of Grout Used: I AL- Casing Type: <br /> r <br /> OWell Installation OWell Destruction Blank _Feet Screer Feet <br /> ❑Boring <br /> eet- <br /> DBoring InstallationlZBoring Destruction Slo_'L Size: <br /> Bags of Cement' <br /> Nq E T H 0.D US D Bags Sand./Gravel: <br /> Ty <br /> ElOverDrill pe/Brand of Bentonite: <br /> L Filter Pack Type/Size: <br /> Ell Gravilv OlTremie 0 Ot-h e F: Type of Method: <br /> er Cennent 471b vVe".El. Cernent 941b <br /> gallons Bags <br /> ca_ .._ ��­z-_. ..- ,� _ -P"-k rN x m-i <br /> cka�i Tihmnest g gs F <br /> __ - 'I"; -K <br /> ni a thinnost B-ag i 1. .3' <br /> Tj T i S�S F.I L <br /> 10 1 Ben"LoIlIr'O Pei-4f l") -1.11. 2.47 <br /> 10 I 2 io i -"0 + i"e 1 e r 4 1 b <br /> L 2.el 21 4.71 <br /> 15 s <br /> _1.5 1 15 30 <br /> 113 I 20 I4 ja I 40 IA <br /> 12.52 5 5 25 1 50 5 <br /> I -_— - —_I ---I— <br /> I_01 6 so H I 6 <br /> 17.z <br /> —35 7 70 7 <br /> n it I I Q 20 0 <br /> F <br /> 10/16/20-17 <br /> 1868 E. H­Re�or,Alder--ue 183'fockton. California 95205 I T 203 468-.3420 I F 203 46-4-0.138 1 <br />