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casing <br />height <br />CMS' 47Y-BOX <br />comPtEnCN <br /> SANdOAQUIN <br />ic.4'4) —COUNTY <br />Greatness grows here <br />Date:(t <br />Facility Add ess: 2 2 1 toi <br />Well Address: a_t o K <br />wp# (1).00-1 Well#: <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: , <br />Consultant: 6.:( v't I fly el.r0 <br />Geologist: 170.4";ii (124,--- <br />Public Water System Onsite: n Yes n No <br />Domestic Well Onsite: DI Yes n No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: 0 Yes 0No <br />SPOILS <br />Contamination Noted: n Yes 0No <br />If yes, spoils storage Location: r;.. W <br />Covered: Yes E No <br />If yes, material: letdrie— ir-thX( ":"Fo-i'vtVA..--- <br />GROUTING or DESTRUCTION Total Depth: cc-4 <br />Depth to Water: k02--- <br />Grout Material: 1711-6‘-4- <br />Gallons of of Grout Used: <br />LII Well Installation '7k/ell Destruction <br />n Boring Installation E Boring Destruction <br />METHOD USED <br />El Pressure Grout ver Drill <br />E Gravity erV lerr-:10ther: <br />Water <br />gallons <br />Cerne 47Ib <br />Ba <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest P Bags Thickest Thinnest 4 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 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 />Environmental Health Department <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: 0 Yes riNlo <br />From: To: <br />From: To: <br />From: To: <br />From: To: <br />COMPLETION E Stove Pipe n 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% Mix 5% Mix <br />Bentonite per 47 lb 1.41 2.47 <br />Bentonite per 94 lb 2.82 4.7 <br />er- S-ed--v% a-33 <br />Monitoring Well/Soil Boring Inspection Report <br />Inspector(DP140^- A CONSTRUCTION <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />10/16/2017 <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com