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(1`)6 SAMAQUIN <br />COUNTY <br />Environmental Health Department <br />Greatness grows here <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 012S1 2i Inspector: ..3c.knetS CONSTRUCTION <br />Facility Address: °\SO si-e4,aft <br /> t-Ctth <br />WP# COLt 166 -5 t" Well#: <br />Soil Boring#: C PT <br />tkiactle, Vir-‘ <br />?)obli3t, <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: LI Yes EINo <br />To: <br />To: <br />To: <br />To: <br />Consultant: <br />Geologist: <br />Well Address: <br />Drilling Company: <br />Driller Onsite: Screen Length From: <br />Filter Pack <br /> <br />From: <br />Bentonite From: <br />Grout From: <br />Public Water System Onsite: 0 Yes 0No COMPLETION 111 Stove Pipe EIChristie Box <br /> <br />Domestic Well Onsite: Yes 111No casing <br />height <br /> <br />If yes, location and distance: <br /> <br />SAMPLING <br />Holding Temperature: <br />Method: <br /> <br />ABOVE-GROUND <br />COMPLETION <br /> <br />C0iRISTY-BOX <br />COMPLETION <br /> <br />Ground Surfacio <br /> <br />Screening Method: <br />Verified Chain of Custody: LI Yes El No — 0.:231aheY.‘ <br />SPOILS <br />Contamination Noted: 0 Yes EN() <br />If yes, spoils storage Location: <br />grout <br />Covered: 0 Yes ENo <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: Ok- - <br />Depth to Water: <br />Grout Material: Nsexk-- <br />Gallons of Grout Used: <br />Water <br />gallons <br />Cement 47Ib <br />Bags <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest #Bags Thickest Thinnest //Bags <br />2.5 5 1 5 10 1 <br />5 10 2 10 20 2 <br />7.5 15 3 1/1,..15 30 3 <br />10 20 4 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 />MATERIALS/DEVELOPMENT <br />Casing Type: <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 />10/16/2017 <br />IOTA <br />OWell Installation OWell Destruction <br />EBoring Installation f.Boring Destruction <br />METHOD USED <br />ElPressure Grout ElOver Drill <br />El Gravity gTremie ElOther: <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I vvww.sIcehd.com