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Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />,rtv(vbactvtivdTAL JaM Consultant: <br />Geologist: <br />Date: (-7 1 (9 <br />Facility Address: <br />Well Address: <br />Inspector: 3u ccd-L17 c+ <br />Well#: <br />Public Water System Onsite: <br />Domestic Well Onsite: <br />Yes El N o <br />111 Yes 111No <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 /> <br />CHFUSTY-BOX <br />COMPLETION <br />Grvund Surfacs <br /> SA 114,, Environmental Health Department <br />COUNTY <br />Greatness grows here <br />Monitoring Well/Soil Boring Inspection Report <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: El Yes ON° <br />SPOILS <br />Contamination Noted: El Yes 1=I No <br />If yes, spoils storage Location: <br />Covered: LIYes IIINo <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: 2,D Ct <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />ElI Well Installation 174Well Destruction <br />El Boring Installation L , oring Destruction <br />METHOD USED <br />ElPressure Grout $Over Drill <br />'‘Gravity ETremie 1110ther: <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />gallons <br />cement 941b <br />Bags <br />Thickest Thinnest #Bags Thickest Thinnest <br />2.5 5 1 5 10 1 <br />5 10 2 10_ , 20 2 <br />7.5 15 3 15 10 30 CD <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 />CONSTRUCTION <br />Total Depth: 201 <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: El Yes EN° <br /> <br />To: <br /> <br />To: <br /> <br />To: <br />To: <br />El Christie Box <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% Mik5..% M...ix. <br />Bentonite per 47 lb 1.41 2-.47 <br />Bentonite per 94 lb 2.82 4.7 <br />10/16/2017 <br />Neat C9-Ptioq— <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com