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� 8 N \�0 O U{N <br /> `���\���U��UQ\\� Einv^ron00entml 8UeaKffi Department <br /> ---c�oUNTY-- ^ <br /> Gmcunm, grows here, <br /> MOn'fOr'Dg Well/Soil BO['Dg iD5D8Ct~OD Report <br /> Date: inspector: CONSTRUCTION <br /> Add� � <br /> Rud\�x res <br /> VVeUAddress: w Total Depth: <br /> VV DriUingRigTvpe: <br /> -oil---'^'g'' P�\nZ"Annular EHD Sea]Ve��ad: []Yes []No <br /> Drilling Company, Screen Length Fronn: To: ________ <br /> Filter Pack FronnL To: __�______. <br /> Bentonite From: To: <br /> Geologist: '------ '-------'-- <br /> Grout Frorn: To:__________ <br /> Public Water System Onoita: E]Yes []0o CO�y�qJET8]N 0 Stove Pipe []Christie Box <br /> Domestic Well Onolte'' ��Yes [�No <br /> � oaziAg ' ' <br /> |f yes, location and distance: <br /> SAMPLING <br /> Holding Temperature: <br /> aum nuSu��o <br /> Method: <br /> Screening Method: Grout <br /> Verified Chain ofCustody: []Yes []No <br /> SPOILS <br /> � . <br /> Contamination Noted: []Yes []No <br /> |f yes,spoils storage Location: <br /> Covered' []Yes []Wo � <br /> ' pmw^ <br />� |f yes, material: <br /> Total Depth: <br /> Depth to Water: <br /> Grout Material: MATERIALS/DEVELOP M ENT <br /> Gallons-- of Grout— Casing Type: <br /> OWel||nstaUation Awell Destruction BlankFeet ' Screen Feet <br /> Slot Size: <br /> E18od Installation Destruction Bags ofCement: <br /> METHOD USED 8ags3and/Graval: <br /> ' Type/Brand ofBenton�e/ <br /> [�PressureGrout Dover Drill <br /> Filter Pack Type/3ize: <br /> |ty P�ernie ElOther: Type ofMethod: <br /> Water Cement 471b Water Cement 94 1b <br /> ' 10/I6/2017 <br />