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' <br /> v <br /> �r ��� <br /> ---CDUNTY--- ~- ' ^ ~ ~ <br /> MOD'ƒOrin,gWek /SOi/ BO['Og |D5DeCf'OD QeD�l[f <br /> F� \ � <br /> Well Address: Toto| Depth:_______ <br /> yv Drilling Rig Type: <br /> Soil Boring#: Min 2" Annular EHDSeal Verified: [] Yes []No <br /> Driller ScreenLength From: To:_________ <br /> ' - - Filter F To <br /> Consultant: rum� :_________ <br /> Geologist: <br /> Bentonite From: Tn:__________ <br /> Grout From: To:_________ <br /> Public Water System Onsite:� L] Yes []No <br /> {IU\0PJETl{N! [] Stove pipe [][hristieBox <br /> Domestic Well Onsite: [] Yes []No <br /> fl- �o <br /> �as � <br /> |fyes, location and distance: <br /> SAMPLING -' 'R-IaUND <br /> Holding Temperature: <br /> � cca�FUETIow <br /> Method: erou:o&Zfac-. <br /> Screening Method: <br /> Nil, <br /> Verified Chain of Custody: [] Yes []No <br /> SPOILS ----- � <br /> Contamination Noted: El Yes []No � <br /> |fyes, spoils storage Location: | � <br /> = | <br /> Covered: El Yes []No --- � <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth, <br /> y <br /> Depth <br /> Grout Material: <br /> Gallons ofGrout Used: <br /> � <br /> or Casing Type: <br /> LJVVeU Installation []VVeU Destruction B|onk_________Feet Screen Feet <br /> []Boring|nstaU 'ohn� Destruction installation e� ~^} < ^/x�/ 5|»tSiz*: <br /> --- ^ -` -- �~ Bags ofCement: <br /> METHOD USED Bags3and/Grave|: <br /> Type/BrandofBentunite� <br /> []PressureGrout []OverDrO| � <br /> Filter Pack Type/Size: <br /> [] Gravity VTTremie []Other: Type of Method: <br /> ,ter Ce M 21-It 9 113 <br /> Water Cement 4-11) VV, <br /> gallons 62gs �allons Bags <br /> Thickest Thinnras, 41 Bqgs Thickest Thinn s" Bags r3eralto�litajceralen' Lr pdiix 30y'. f4iy 5% 4-fix <br /> "Vill <br /> 2 10 20 Bentonite per 94 lb 2.82 <br /> 30 3 E <br /> i.5 30 6 30 0 OuQ �- �^0 /��/ <br /> -`' ^ � v <br /> v L <br /> 40 8 40 80 2 <br /> IU/Ib/l47 � <br /> 1868 E Hazelton Avenue I 3tookton, California 95205 T 209 468'3420 1 F 209 464-01030' 1 <br />