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• SAN J OA Q U I N Environmental Health Department <br />L:, y —COUNTY— <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />CANAPI II\I(_1 <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 />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />If yes, material: n <br />GROUTING or DESTRUCTION Total Depth: i- I <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />ell Installation ❑Well Destruction <br />❑Boring Installation ❑Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �Tremie ❑Other: <br />Water <br />gall] s <br />Monitoring Well/Soil Boring Inspection Report <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Date: YV f+ Inspector: <br />CONSTRUCTION <br />Facility Address: <br />Well Address: <br />Total Depth: <br />-3--Well#: <br />._3_0_5 <br />WP# O 0 t <br />Drilling Rig Type: <br />Soil Boring#: TJ <br />Drilling Company: <br />p <br />t- t/I Min 2" Annular EHD Seal Verified Yes ❑No <br />1 Screen Length From: ��-� <br />Driller Onsite: <br />�T4— <br />Filter Pack From: 2-q To::3 Qzzs-- <br />Consultant: <br />Geologist: <br />_ <br />Bentonite �gASiKECom: To: � r' _' <br />2 <br />Grout From: To:� <br />Public Water System Onsite: <br />❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />CANAPI II\I(_1 <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 />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />If yes, material: n <br />GROUTING or DESTRUCTION Total Depth: i- I <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />ell Installation ❑Well Destruction <br />❑Boring Installation ❑Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �Tremie ❑Other: <br />Water <br />gall] s <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />#Bags <br />Thickest Thinnest <br />#Bags <br />2.5 <br />5 <br />1 <br />5 10 <br />1 <br />5 <br />10 <br />2 <br />10 20 <br />2 <br />7.5 <br />15 <br />3 <br />15 30 <br />3 <br />10 <br />20 <br />4 <br />20 40 <br />4 <br />12.5 <br />25 <br />5 <br />25 50 <br />5 <br />15 <br />30 <br />6 <br />30 60 <br />6 <br />17.5 <br />35 <br />7 <br />35 70 <br />7 <br />20 <br />40 <br />8 <br />40 80 <br />8 <br />casing <br />height <br />ABOVE -GROUND CHRLSTY43OX <br />COMPLETION COMPLETION <br />Ground Sine" <br />groul <br />tt. <br />tt. <br />2/T o <br />— e <br />C <br />:totted <br />Bacon "— <br />MATERIALVDEVELOPME <br />Casing Type: /' rv'�_ ) <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 />;,.ylz_ 'Xvc <br />n Feet <br />Bentonite/Cement Mix 3% Mix 30% Mix <br />Bentonite per 47 Ib 1.411 2.47 <br />Bentonite per 94 Ib 2.821 4.7 <br />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 />