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SANAOAQUIN <br />COUNTY • <br />Greot nes s grows here. <br />Environmental Health Department <br />107,34( Date: <br />0No 0 Yes <br />To: <br />COMPLETION 0 Stove Pipe 0Christie Box <br />111 Yes ON° Verified Chain of Custody: <br />SPOILS <br />K-(es ON° <br />OC,r1 I' 5 fie-c-- <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />0 Yes TA;Flo <br />r <br />GROUTING or DESTRUCTION Total Depth: ( <br />Depth to Water: - <br />Grout Material: Pe00 - Cl2 <br />Gallons of Grout Used: 'Lou "79-((3.) <br />EWell Installation ell Destruction <br />0Boring Installation 0Boring Destruction <br />METHOD USED <br />EPressure Grout ,r Drill <br />CI Gravity Xrremie ElOther: <br />Screen Feet Blank 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 />Facility Address: <br />Well Adtess: <br />WM_ CV (.11 g We11#: V —S <br />Soil Boring#: <br />Drilling Company: 1) i(01-t7 <br />Driller Onsite: <br />Consultant: <br />Geologist: lir ;(17 <br />Public Water System Onsite: 0 Yes EiNlo <br />Domestic Well Onsite: III Yes 0No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />gallons <br />Cement 94Ib <br />Bags <br />Thickest Thinnest 't Flap Thicket: <br />5 <br />Thinnest n Bags <br />2.5 5 1 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 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 />casing <br />height <br />MATERIALS/DEVELOPMENT <br />Casing Type: <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 />Inspector: <br />tAJ, 104 C_ )1-0ett <br />Monitoring Well/Soil Boring Inspection Report <br />t4-57>KKI CONSTRUCTION <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.com <br />Total Depth: <br />Drilling Rig Type: <br />ABOVE-GROUND <br />OO&FLETIOtg CHRISTY-EpX <br />COMPLETI9N <br />Min 2" Annular EHD Seal Verified: <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />To: <br />To: <br />To: <br />From: <br />From: <br />From: <br />From: