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� �� <br /> ' -- COUNTY—'- '' ' <br /> Mon'tOriDgUVe|l /S0'l AOr'Dg !DS[}e[ƒiOO Report <br /> Date: In spector: Ta.'e. / ds o CONSTRUCTION <br /> Facility AddAve <br /> Well*uu Total Depth:_______ <br /> yv ~ Drilling Rig Type: <br /> -Soil Borin Min 2^ Annular EHDSea[Verified: [] Yes []No <br /> Drilling Company-. - - ' �� Screen Frum�______� To: <br /> D.".e. Onsite: <br /> [onsu|ton Filter Pack From� To: ________ <br /> Geo|ogist: Bentonite From: To:_________ <br /> Grout From: To:_________ <br /> Public Water System Onsite:� [] Yes []No <br /> {%OVKqJBO{*� [] Stovepipe [][hristieBox <br /> Domestic Well Onsite: [] Yes []No <br /> c�s�co <br /> |fyes, location and distance: hegut <br /> 3/UVKPLI*G ABOVE-GROUND <br /> Holding Temperature: <br /> powpLsrmw canor���x <br /> � ccxFus�ow <br /> Method: <br /> Screening Method: <br /> Verified Chain ofCustody: [] Yes []Nu <br /> SPOILS <br /> Contamination Noted: [] Yes []No s <br /> |fyes,spoils storage Location: <br /> Covered: El Yes []No / <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: / <br /> Depth -----'�' -�---E����J «' <br /> Grout Material:. <br /> Gallons ofGrout Used: <br /> Casing Type: <br /> []VVe|| Installation []VVe|| Destruction Blank Feet Screen Feet <br /> � <br /> []8ur/ng|nsta||ation VM�oring Destruction Slot Size' <br /> Bags of Cement: <br /> METHOD USED Bag»Send/Gmve|: <br /> � <br /> []PressureGrout []OverDhType/BrandofBentonite� <br /> || <br /> Fi|terPackType/�ize� <br /> [] Gravity []Tremie ��Other: �� Type of Method: <br /> Water Cement 47 11) VVater Cern ent 941 11) <br /> S Bags <br /> 5 -10 Bentonife per 47 lb 1 1.41 2.471 <br /> 156 30 60 � <br /> �x <br /> & Pdy4jaj �^ �' � 1G/2O17 <br /> ` ` ~ U / <br />