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— <br /> �8N1�&OU�N <br /> �MiH������U||� Environmental HeaU�� ���a�00ent <br /> r ---{�[>UNTY--- ^ <br /> ` Grezness 9m", here. <br /> Monitoring Well/Soil Boring Inspection R8DO[f <br /> Y' � ^ t, //� STRUCTION <br /> Date | dk��b/c4 <br /> Facility Address:_ c/ 74,1A /Z.oCl/ <br /> Well Address: LJLI �Oi ITotal Depth: <br /> WP# Well#: Drilling Rig Type: <br /> 5oi| 8ohng# �-^� <br /> Min Z"Annular EHD Seal Ver� �ed� ��Yes []Nu <br /> DhUinQ[ompan <br /> DhUer0ns�e: Screen Length Fonm� Tu�__________ <br /> ' � FilterPack From:� To: <br /> Consultant: �---------- <br /> Geologist: Bentonite From: To: <br /> Grout From:_'1/0'_ To: 0____ <br /> Public Water System Onsite: [] Yes []No COMPLETIONi [] Stove Pipe []Christie Box <br /> Domestic Well Onsite: [] Yes []No <br /> casing <br /> |f yes, location and distance: height <br /> SAMPLING o Holding Temperature: coWusxzm —'-- ' . <br /> COMPLETiON <br /> Method: aodnumvx=s <br /> Screening Method: grout <br /> Verified Chain ofCustody: [] Yes []No <br /> SPOILS | <br /> Contamination Noted: El Yes []No <br /> |f yes,spoils storage Location: *m/ <br /> Covered: [] Yes []No -- � <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: � NNER <br /> � <br /> Depth tuWater: <br /> Grout Material: <br /> Gallons ofGrout Used: <br /> Casing Type: <br /> `_~�� � <br /> psfve|| |nsto||ation LJVVe|| Deotruction Blank Feet Screen Feet <br /> L]Boring Installation []BoringDestruction Slot Size: <br /> Bags ofCement: <br /> METHOD USED BaQsSund/Grave|: <br /> Type/BrandofBentonite� <br /> []P�ssune6nout []OverDri|| <br /> Filter Pack Type/Size: <br /> [] Gravity ~S- mie []Other: Type of Method: <br /> Water Cement�471b Water Cement 94 lb <br /> gall 5 �Ba 5 gallons Bags <br /> Thickest Thinnest #Bags Thickest Thinnest #Bags Bentonite/Cement Mix 3% Mix 5% Mixi <br /> 1O/16/ZO17 <br /> 1868E. HazaUnnAvenue Stockton, California 052O5 T 209488-34201 F 209464'0138 1 <br />