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Date: 03 <br />Facility Ads ress: <br />Well Address: <br />Inspector: s <br />vo# opit(9)34 Well#: <br />Soil Boring#: 6 -3 6s- <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: ck,t) • <br />Public Water System Onsite: LI Yes IDNo <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />COMPLETION <br />From: <br />From: <br />From: <br />From: <br />El Stove Pipe <br />casing <br />height <br />ABOVE-GROUND <br />COMPLETION CHRISTY-BOX <br />COMPtETION <br />Ground Surfacs <br />Blank Feet Screen 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 />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 lb 1.41 2.47 <br />Bentonite per 94 lb 2.82 4.7 <br />, AN S,JOAQUIN <br />COUNTY <br />'<tyke' ureatness grows hers? <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ID Yes ON° <br />To: <br />To: <br />To: <br />To: <br />D Christie Box <br />Domestic Well Onsite: LI Yes El No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: III Yes lii No <br />SPOILS <br />Contamination Noted: I=1 Yes D No <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: al‘ 3 la)K ) <br />Grout Material: <br />Gallons of Grout Used: 5 cy.A. ,9,110-1 259 64 <br />LII Well Installation LIWell Destruction <br />Boring Installation,6Boring Destruction <br />METHOD USED <br />Pressure Grout DOver Drill <br />M Gravity <br />Water N nent <br />gallons <br />47Ib <br />Bags <br />Water <br />gallons <br />Cement 94Ib <br />Bags <br />Thickest Thinnest # Bags Thickest Thinnest # Bags <br />2.5 5 1 i.v.' 5 10 1 <br />5 10 2 e.,'" 10 20 2 <br />7.5 15 3 t., 15 30 3 <br />10 20 4 i."- 20 40 4 <br />12.5 25 5 25 50 5 <br />15 30 6 30 60 6 <br />17.5 35 7 35 70 7 <br />20 40 8 40 80 8 <br />El Yes <br />El Other: <br /> <br />grout <br />ft <br />10/16/2017 <br />c;=14Nrce g <br />WIC' <br />61-1- 104-, <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sioehd.com