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SAWJUMIN Environmental Health Department " —COUNTY— `'+i,popF+' Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date: �\- inspector: CONSTRUCTION Facility Address: ','Ob Well Address: '4j0 L--k- tj� KN Total Depth: WP# VJe Well#: W�A'_ Drilling Rig Type: Soil Boring#:_ 'S Drilling Company: Lsrr�h Min 2" Annular EHD Seal Verified: ❑ Yes ❑No Driller Onsite: Screen Length From: To: Consultant: tnC-'o✓ )D ZLF.!Z jz> Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: Pf Yes ❑No COMPLETION ElStove Pipe ❑Christie Box Domestic Well Onsite: ElYes IJ1NO casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: coh4PLETION COMPLETION Method: errand 9wlacr — Screening Method: orart Verified Chain of Custody: ❑ Yes ❑No —h• tt. SPOILS Contamination Noted: ❑ Yes ❑No ' If yes,spoils storage Location: abtmd aeon R Covered: El Yes ❑No Qmvigvack If yes, material: c GROUTING or DESTRUCTION Total Depth: Depth to Water: TM• " — n Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: :� 5 �u 1DtO�' Casing Type: ❑Well Installation 6WellDestruction �rF Blank Feet Screen Feet ❑Boring Installation ❑Boring,Destruction Slot Size: Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout Dover Drill Filter Pack Type/Size: Gravity ❑Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 94lb allons Bags gallons Bags Thickest Thinnest #Bags Thickest Thinnest #Bags Bentonite/Cement MIX 3% MIX 5% Mix 2.5 5 10 1 _ Bentonite per 47 lb 1.47 2.47 5 10 10 20 2 Bentonite per 94 lb 2.821 4.7 7.5 is 3 15 30 3 30 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 10/16/2017 4o1n 1 „---:a.._. n.._.... : na__,.a__ n..s..._:.. ncnnc : r nnn een n4nn : r nnn 4e4 n400 : ........._;__ate __....