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'A N 1111 0 A 0, V I N <br /> H, LV­ <br /> it i g W I �,o i I B or i r i g r, p e CtJ c)n R e p o rt <br /> Date: Inspector: CUP C 0 N S T R UC T M IJ <br /> —7 <br /> i-acilityAddress: MOM S. 1144001 kX <br /> -Well Address: Total Depth: <br /> W P t",-qQ1 Drilling Rig Type: <br /> 1�� W e I I <br /> Soil Boring#: 0% Min 2" Annular EHD Seal Verified: 0 Yes ONo <br /> Drilling Company: �M" AD <br /> Driller Onsile: ummstj Screen Length Frdm� To: <br /> CoIIs,jlL,3nt: Filter Pack From:_ To: <br /> Geologisi t: Bentonite From: To: <br /> GroUT From: To: <br /> Public Water Systern Onsite: 1:1 Yes EINo C-0-IMP LETION El Stove Pipe ElChristie Box <br /> Donne-stic Well Onsite: Ol'lies EJNo <br /> --;.,r -, *­�q, I <br /> n rzz:q� c <br /> 11 yes, location and clist@nce: <br /> t <br /> SAMPLING c <br /> 1-Itc-11ding Ternperat-ure:_ <br /> MeL locl: <br /> Screening Miethod: grat <br /> ILI <br /> Verified Chain ofCustody: 0 Yes Ej_N[0 <br /> SPOH S <br /> u <br /> -7. <br /> Conta,mination Noted: El Yes EJNo <br /> 11 ye-s, spoils storage Location: <br /> Covered: 0. Yes Ej-.,'\l o E <br /> ZIA <br /> DF-STRUCTION Total <br /> GROUTING ot Depdh: I-a f <br /> �4, INC. <br /> Dm-ID-Lh to Vvater: <br /> Grout I'Viaterial: fKUIOD CEW 4V'L- <br /> of(33rout Used: J 6k\.- <br /> L <br /> Casing lype: <br /> EIVVell Installation D,Jvell DESIIII!Cti011 Blank —reet Screen—Feet- <br /> 108oring Installation IAB-Ioring De-struction SJO'�Si7e: <br /> Bags of Cement <br /> V E H G D U SE U, Bags Sand/Gravel: <br /> OPressure Gr.:)U'I ClOver Drill Type/Brand ol E-entorlite: <br /> Filter PaCj<_1�!Pej"Sj7e: <br /> Ell Gravitv E]Tremie Elother: Type ol Method: <br /> E f' ca!nell- C2m2n-,94H) <br /> �u cin S Rmilons <br /> Mix ki <br /> V.ild-ESUL Thinoaz, efisent <br /> 1.4 1 2.-1,7 <br /> 5 5- Pal 1-b <br /> 20 _�G Fro_en-ionile per_Q,4 lb e.21 4,71 <br /> 15 3 -15 0 3 <br /> 20 4 -50 All <br /> 1— -50 <br /> 12 5 25 <br /> 5 <br /> IS 6 60 6 <br /> 33 1 7 10 <br /> �20`7 <br /> LO/_ <br /> 1868 E.Fiaze�on Avarua Stockton, Californfa 9520.5 T 209 4B8-.3420 F 209 4,64-0-138 www.SIcehd.ccn1 <br />