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SAN ;JUA(JUIN <br />--COUNTY <br />C,r'aotncss <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: Inspector: &!h CONSTRUCTION <br />Facility ddress: 24Sc� <br />Well Address: <br />WP#�,g% Well#: <br />Soil Boring#: _R y <br />Drilling Company: I 114A) <br />Driller Onsite: <br />Consultant: h e Zae_ <br />Geologist: <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />From: <br />Filter Pack <br />From: <br />Bentonite <br />From: <br />Grout <br />From: <br />Public Water System Onsite: ❑ Yes E] No COMPLETION ❑ Stove Pipe <br />Domestic Well Onsite: ❑ Yes 11 No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody: <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: �p,�u.✓ <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation XBoring Destruction <br />METHOD USED <br />EJ Pressure Grout Over Drill <br />❑ Gravity ❑Tremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />eallons <br />Cement 941b <br />Bags <br />Thidrest Thinnest <br />#Bags <br />Thickest Thinnest <br />#Bags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 10 <br />2 <br />10 20 <br />2 <br />7.5 15 <br />3 <br />15 30 <br />3 <br />10 20 <br />4 <br />20 40 <br />4 <br />12.5 25 <br />5 <br />25 50 <br />5 <br />15 30 <br />6 <br />30 60 <br />6 <br />17.5 35 <br />7 <br />35 70 <br />7 <br />20 40 <br />8 <br />40 80 <br />8 <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />casing <br />height <br />ABOVE -GROUND CHRiSTY43OX <br />CO&FLETION COMPLETION <br />Ground surface <br />grout <br />n. <br />ft. <br />n. <br />_ o <br />— o <br />slotted <br />sec�on <br />gravel pack <br />R. ft. <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />Screen Feet <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />or,< 10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />