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Date: Inspector: <br />Facility ddres <br />Well Address: <br />WP# 03 yO Well#: /4i,1 7 <br />sQii_aor4Rtiti 2 / <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />g6kr <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: Ill Yes LiNo <br />To: <br />To: <br />To: <br />To: <br />Screen Length From: <br />Filter Pack <br />From: <br />Bentonite From: <br />Grout <br />From: <br />COMPLETION CI Stove Pipe El Christie Box <br />casing <br />height <br />CHIRIST+-S,OX <br />COMPLETION <br />Grociecl Surface ,==4 <br />giout <br />40; ft <br />ft. <br />vs SANJOAQUIN. <br />COUNTY <br />cireatriess grows U,.re <br />Environment Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Public Water System Onsite: <br />Domestic Well Onsite: <br />If yes, location and distance: <br />Screening Method: <br />Verified Chain of Custody: <br />Yes EINo <br />SPOILS <br />Contamination Noted: El Yes LiNo <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />1 6 GROUTING or DESTRUCTIFIIN Total Depth:Z,,r 6 1 <br />• Depth to Water: i t <br />Grout Material: _,I <br />Gallons of Grout Used: V) 0 [ 3 <br />OWell Installation ell Destruction <br />OBoring Installation Li Boring Destruction <br />METHOD USED <br />LI X <br />Li Gravity remie DOther: <br />Water <br />gallons <br />Cement 47 lb <br />Bags <br />Water <br />gallons <br />cement 941b <br />Bags <br />Thfckest Thinnest ft Bags Thickest Thinnest 4 Sags <br />2.5 5 1 5 10 1 <br />5 10 2 10 20 2 <br />7,5 15 3 15 30 a <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 60 a <br />CONSTRUCTION <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 />LI Yes CINo <br />El Yes El N o <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Yes ON° <br />Pressure Grout Over Drill <br />3° <br />'1868 E. Hazelton Avqfiue I Stoq9ton, California 95205 f T 209 468-3420 F 209 464-0138 I www.sicehd.com <br />10/16/2017