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)AA�.1,JUAUU114 <br /> —COUNTY— Environmental Health Department <br /> - l <br /> / Greotns, 9rnpv-s here. <br /> .. <br /> MODitOr'D�� VV��|�SO'| �\O['D� |D3O�Cƒ'OD R{�OOF[ <br /> � � � � <br /> Date: <br /> l Facility Address: k-wo <br /> Well Address: Total Depth: <br /> VV |#h <br /> Drilling Company: P-4-,iA4c4,-e- ov-#144—\ fl 116­J1 P4 Min 2"Annular EHD Seal Verified: E] Yes E]No <br /> Driller Onsite: kk�!�At'j f,1,7d-014 Screen Length From:_ To: <br /> Consultant: Filter Pack From: To: <br /> Public Water System Onsite: El Yes ONo COMPLETION. El Stove Pipe ElChristie Box <br /> Domestic Well Orohe: O Yes [­lNo <br /> cas.Lnn <br /> If yes, location and distance: helsut <br /> SAMPLING ' <br /> Holding Temperature: oompuETjom . ---' <br /> c�mouau�=s <br /> Method: <br /> Screening Method' grout <br /> Verified Chain ofCustody: III Yes []No <br /> SPOILS <br /> Contamination Noted: LJYes []No ~ <br /> |f yes, spoils storage Location: <br /> Covered: []Yes []No <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: 5;K1 <br /> 6 ' <br /> Depth to Water: ----_^� � <br /> Grout Material: /V'-t MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: \ /(«j CadngType: <br /> LJWe | |nstaUotion []VVe | Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> LJBuhn8/n�aUat�n �J�8hn�Destrucbon <br /> ~ Bags of Cement: <br /> METHOD USED 8agsSan6/Grave|: <br /> Type/8ran6ofBentonite'� <br /> []Pressure Grout []OverDri|| <br /> Filter Pack Type/Size: <br /> =< ity OTremie OOther: Type ofMethod: <br /> Water Cement 471b Water Cement 941b <br /> gallons Bags gallons Bags <br /> Thickest Thinnest 4 Bags Thickest Thinnest #Bags Sentonite/Cement Mix 3% Mix 5% Mix- <br /> 10 20 4 20J 40 4 <br /> E3151 7 35 70 7 <br /> 20 40 8 240 80 8 <br /> lO/l6/2O17 <br /> 1868 E. Hazeiton Avenue I Stookton, California 85205 1 T 209468-3420 1 F 200464-0138 1 <br />