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SANAOAQUIN <br />-1,:attar :".1 COU NTY-- <br />\ .11Szio" Greatness grows here <br />Environmental Health Department <br />Yes ON° Verified Chain of Custody: <br />SPOILS <br />casing <br />height <br />ABOVE-GROUND <br />COMPLETION C1RISTY-BOX <br />COMPLETION <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 71 2-1 Inspector: 50, ( CONSTRUCTION <br />Facility Add ess: 26[5-'1 (Oa <br />Well Address: <br />WP# <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />Public Water System Onsite: LI Yes EiNo <br />Domestic Well Onsite: LI Yes EINo <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Contamination Noted: LI Yes ON° <br />If yes, spoils storage Location: <br />Covered: LI Yes EINo <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water:NV Q LAyki(- <br />Grout Material: _k)..)\--C•ycni.e(1,-\- <br />Gallons of Grout Used: <br />LIWell Installation 111 Well Destruction <br />111 Boring Installation OBoring Destruction <br />METHOD USED <br />IEIPressure Grout DOver Drill <br />LI Gravity ETremie DOther: <br />Water <br />gallons <br />Cement 47Ib <br />Bags <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest #Bags Thickest Thinnest It Bags <br />2.5 5 1 5 10 1 <br />5 10 2 10 20 2 <br />7.5 15 3 15 30 3 <br />10 20 4 20 40 4 <br />12.5 25 5 25 SO s <br />15 30 6 30 60 6 <br />17.5 35 7 35 70 7 <br />20 40 8 40 80 8 <br />Blank Feet Screen <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 />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.corn <br />Well#: <br />Total Depth: <br />f <br />grout <br />-tt <br />ft <br />Drilling Rig Type: <br />COMPLETION LI Stove Pipe LlllChristie Box <br />Ground Surface <br />slotted <br />&action <br />gravel pack <br />ft. <br />Min 2" Annular EHD Seal Verified: <br />From: <br />From: <br />From: <br />From: <br />LI Yes IJNo <br />To: <br />To: <br />To: <br />To: <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Feet