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1.�.� <br />-Environmental Health Dep <br />artmehtI coo Y— <br />Grw.'"ss <br />groins hero. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: K Insp�ec�t�or: gNV%a Vk_ I_- CONSTRUCTION <br />Facility Address: yp Nf o `Wf Ilan O - <br />Well Address: Total D th <br />Soil Boring#: f( -a <br />Drilling Company: <br />Driller Onsite: _ <br />Consultant: <br />Geologist: A5 <br />Public Water System Onsite: <br />Wel <br />ep <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />From: <br />Filter Pack <br />From: <br />Bentonite <br />From: <br />Grout <br />From: <br />❑ Yes []No COMPLETION ❑ Stove Pipe <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />❑ Yes ❑No <br />❑ Yes ❑No <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />i <br />GROUTING or DESTRUCTION Total Depth:_&Q_ <br />Depth to Water: Vl0 CAda. e -v- <br />Grout Material: C'"yy <br />Gallons of Grout Used: <br />❑Well Installation OWe11,Destruction <br />DBoring Installation >*o ring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity 'WTremie []Other: <br />casing <br />heightJil _T <br />' <br />ABQIWS-t5F1L7tJND ui1 SaX <br />colst Bnor� CHRCOWLlTIOt3 <br />Orocd <br />ft. <br />#t. fl- <br />w <br />- iloY�d Y_i �� •� <br />x01 Pack <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />K -A <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: _ <br />Filter Pack Type/Size: <br />Type of Method: <br />Screen Feet <br />water <br />Cement 471b <br />Water <br />Cement 941b <br />alions <br />Bags11 <br />gallons <br />Bags <br />Thickest Thinnest <br />;;Bags <br />Thickest Thinnest <br />#Bags <br />BentonitefCement Mix 3% NX 5%, MIX <br />25 <br />s <br />1 <br />s <br />l0 <br />1 <br />B'a 'on per 4716 <br />1.41 2.47 <br />s <br />7.5 <br />10 <br />2 <br />10 <br />2D <br />2 <br />3 <br />Bentonite per 94 lb <br />2.82 4.7 <br />15 <br />3 <br />15 <br />30 <br />10 <br />1 20 <br />1 4 <br />20 <br />40 <br />q <br />1 t t <br />125 <br />25 <br />5 <br />25 <br />s0 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60. <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 1 <br />40 <br />80 1 <br />8 <br />JfO <br />��� <br />10/16/2017 <br />1868 E. <br />HaAltort <br />Avon l.ie j Sfockton, Califa mia 952051 T 209468-34201 F 2094640138 <br />1 Www.sicehd.com <br />