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SAN«10AQUIN <br />" Ukt' ,_ —COUNTY— — <br />9,.,Foa�` Greatness grows here <br />Environmental Health Department <br />V „ CM <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes El No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes El No <br />If yes, material: <br />GROUTING or DESTRUCTION Total De th:_) <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: N, `/ 0 <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Coring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �emie <br />❑Other: <br />Water <br />allons <br />Monitoring Well/Soil Boring Inspection Reporl <br />Date: $ <br />InspecV " <br />CONSTRUCTION <br />Facility Address:5- <br />cttgr: <br />Kd 1 <br />4Bags <br />Well Address: <br />#Bags <br />Total Depth: <br />WP# <br />Well#: <br />Drilling Rig Type: + J� <br />Soil Boring#: <br />1 <br />Min 2" Annular EHD Seal Verified: <br />10 <br />Drilling Company: <br />K <br />20 <br />Driller Onsite: <br />��..--�-r � r, ` <br />Screen Length From: <br />Consultant: <br />Cot S C� <br />Filter Pack From: <br />Geologist: <br />V �T�Vi',� <br />Bentonite From: <br />4 <br />20 <br />Grout From: <br />V „ CM <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes El No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes El No <br />If yes, material: <br />GROUTING or DESTRUCTION Total De th:_) <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: N, `/ 0 <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Coring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �emie <br />❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />4Bags <br />Thickest Thinnest <br />#Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 1 <br />60 <br />6 <br />17.5 <br />20 <br />35 <br />40 <br />7 <br />8 ' <br />35 <br />70 <br />7 <br />40 1 80 <br />8 <br />3 i L Z(� <br />k <br />Plus b, r� Zelooin1868E. Avenue I Stoction, California 95205 <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 />T 209 468-3420 1 F 209 464-0138 1 www.sucehd.com <br />