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� 8N |M8�U�N <br /> �A\V��U���W|N Environmental Health DeK���mm���t <br /> � --^-COUNTY--- Department <br /> - <br /> Grcomuo ymwm here, <br /> Monitoring Well/Soil Boring |DspeCƒ'On Report <br /> FacilityDate:','. -inspector: CONSTRUCTION <br /> . ....^~~ <br /> Well Address: Total Depth: <br /> WP# wellt Drilling Rig Type: <br /> ywu h <br /> ��~� ' i�(Min 2"Annular EHD Seal Ve �ed: El Yes []Nu <br /> Drilling Company: V',A-�Driller Onsite: x - ^ ' ' Screen Length From� Tn:__________ <br /> Filter Pack From: ' <br /> To <br /> Consultant: `------ `--------- <br /> Geologist: 8entnnite From: To:_________ <br /> Grout Frnm: To:__________ <br /> Public Water System Onxite: O1 Yes []NoCOMPLETION [] Stove Pipe []Chhstie8ox <br /> Domestic Well Onsite: LJ Yes No 7- casing ' . <br /> |f yes, location and distance: ' height <br /> 1.- 1 "�4�3 ' <br /> SAMPLING o <br /> Holding Temperature: mOmPLovOm CWPLETiON <br /> -'--'' <br /> Method: orom*ywwace <br /> Screening Method: grout <br /> Verified Chain ofCustody: [] Yes []No <br /> SPOILS i <br /> � . <br /> Contamination Noted: []Yes []No ° <br /> |f yes,spoils storage Location: <br /> Covered: []Yea []Nu '- � <br /> |f yes, material: , <br /> GROUTING or DESTRUCTION Tota| Depth ~ A <br /> . �-~�----_ <br /> Depth ~~~-~��«� ~�-~-����^-J <br /> GruutMater|a|: "N MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> []VVeU Installation OVVeU Destruction Blank Feet Screen Feet <br /> []8ohn8 Installation []8ohn8Destruction Slot Size: <br /> Bags ofCement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of8entonite� <br /> [lPreasuro Grout []OverDri|| Type'/ <br /> Filter Pack Type/Size: <br /> [] Gravity r�Tremie r�other: �5 Type of��ethud' <br /> � ' <br /> water Cement 471b Water Cement 941b <br /> - <br /> gallons Bags eall! s Bags <br /> Thickest Thinnest Bags Thickest Thinnest #Bags Bentonlite/Cement Mix 3% Mix <br /> - 10/16/2017 <br /> 18G8E. Hazalton Avenue I Stockton, California 95205 | T 209468'34201 F 200464-0138 1 <br />