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SAN.:J0AQUIN <br />—COUNTY- <br />Greatness <br />COUNTY— <br />Greatness grows here. <br />Environmental Health Department <br />Domestic Well Onsite <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 />❑ Yes ❑No <br />❑ Yes El No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION I Dh: <br />0,/4 <br />Depth to Water: 1 <br />Grout Material: <br />Gallons of Grout Used: (o) 0"1�i r-31 <br />❑Well Installation []Well Destruction <br />[IBoring Installation oring Destruction <br />METHOD USED <br />El Pressure Grout ❑Over Drill <br />r�Gravity ❑Tremie El Other: <br />Water <br />allons <br />Monitoring Well/Soil Boring Inspection Report <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Date: 1 / l Inspector: <br />CONSTRUCTION <br />Facility Address: .11,Well <br />#Bags <br />2.5 <br />Address: <br />1 <br />Total Depth: <br />WP#ell#: <br />—610 <br />Drilling Rig Type: <br />Soil Boring#: <br />10 20 <br />2" Annular EHD Seal Verified: El Yes El No <br />7.5 <br />Drilling Company: <br />tea' LSI--C <br />15 30 <br />Driller Onsite: <br />10 <br />Screen Length From: To: <br />Screen <br />Consultant: <br />Filter Pack From: To: <br />Geologist: <br />25 <br />�Bentonite From: To: <br />25 50 <br />5 <br />Grout From: To: <br />Public Water System Onsite: <br />❑ Yes <br />El No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite <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 />❑ Yes ❑No <br />❑ Yes El No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION I Dh: <br />0,/4 <br />Depth to Water: 1 <br />Grout Material: <br />Gallons of Grout Used: (o) 0"1�i r-31 <br />❑Well Installation []Well Destruction <br />[IBoring Installation oring Destruction <br />METHOD USED <br />El Pressure Grout ❑Over Drill <br />r�Gravity ❑Tremie El Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest ThNapest <br />4.0 <br />Thickest Thinnest <br />#Bags <br />2.5 <br />5 <br />1 <br />5 10 <br />1 <br />5 <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 />n. <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 />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s'cehd.com <br />