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' <br /> �� �K�&��U� <br /> .���U������V�n�UU� Environmental ��. ������tn����� <br /> ---COUNTY--- ��� ---' '--'—' --^Department <br /> Gmvma, ym"n here. <br /> MoO'for'n2WpU/SO'/ Boring |OSpeCf'On Report <br /> Date: Inspector:/n^pectoc <br /> Facility Address: A-Y� ' <br /> Well Address: ^ " Total Depth: <br /> «« 011] Drilling Rig Type: <br /> So | aonng#: MIAq ' <br /> � Min Z"Annular EHDSeal Verified: [] Yes []No <br /> Drilling Company: - ^ Screen Length From: 'To� <br /> Driller Onsite: <br /> Consultant: '' To: <br /> '------- ---------- <br /> Filter Pack From <br /> ------- �----�----- <br /> Geologist: Bentonite Fnorn: To:__________ <br /> Grout From: To:__________ <br /> Public Water System Onsite []Yes []No COMPLETION. [] Stove Pipe []Christie Box <br /> Domestic Well Onsite: [] Yes []No <br /> casing <br /> |fyes, location and distance: height <br /> SAMPLING o <br /> Holding Temperature: COMPLETION —'—'' <br /> COMPLETjON <br /> Method: ovotiououm=w <br /> Screening Method: grout <br /> Verified Chain ufCustody: [] Yes []No <br /> SPOILS | <br /> � <br /> Contamination Noted: El Yes []Nu <br /> |fyes,spoils storage Location: <br /> n � | <br /> Covered: [] Yes []Nogra Pack <br /> � <br /> |fyes, material: <br /> GROUTING or DESTRUCTION Total Depth: � <br /> Depth toWater ```-»6Ur ~-----^/t. ~ F <br /> Grout Material: <br /> Gallons ofGrout Used: <br /> Casing Type: <br /> ] 0� �� w��� *\�t��r <br /> []VVe/| |nsta||ation []xve// ���fF6ction B|ankFeet Screen Feet <br /> �.� Slot Size: <br /> LJBohn�|nstaUation���ohnQDe�tr«cti«n Bags ofCement: <br /> METHOD USED Bugs Sand/Gravel: <br /> []PressureGrout []OxerDri|| Type/Brand ofBentonite: <br /> Filter Pack Type/Size: <br /> rn/Gravit '.4Tremie []Other: Type of Method: <br /> Water Cement 47 lb Water Cement 941b <br /> Thickest Thinnest k,Ba gs Thickest Thinnest 9 Bags Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 5 10 1 1 Sentonite per 47 lb 1.41 2.47' <br /> Bentonite per 94 Ib 2.82 4.7 <br /> lo 20 4 20 40 4 <br /> 15 30 6 30 60 6 <br /> 71 <br /> 10/16/ZU17 <br />