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SAN JOAQUIN <br />+-1.41111aw COUNTY <br />aSmo;Greatness grows here <br />Environmental Health Department <br />CIChristie Box COMPLETION 111 Stove Pipe Public Water System Onsite: LI Yes EINo <br />casing <br />height <br />ABOVE-GROUND <br />COMPLETION OHS:STY-BOX <br />COMPLETION <br />Monitoring Well/Soil Boring Inspection Report <br />Domestic Well Onsite: GI Yes LiNo <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: El Yes CINo <br />SPOILS <br />Contamination Noted: LI Yes ON° <br />If yes, spoils storage Location: <br />Covered: LIYes El No <br />If yes, material: itte_vs, rw--06 <br />GROUTING or DESTRUCTION Total Depth: LOS ,ig° I ISO <br />Depth to Water: <br />Grout Material: Peat- <br />era+bms of Grout Used: ^- 6, se- / <br />ElWell Installation Well Destruction <br />EBoring Installation DBoring Destruction <br />METHOD USED <br />Li Pressure Grout 00ver Drill <br />Li Gravity <br />ga4,1„- Ye,/ f,SO , <br />rw-eS .kv-e:36 11.0 ,c1 f-e,d7 /00 <br />e /ylos.;ves gef cro in 19 0 (-6 171 0 *r <br />10/16/2017 <br />(-601 6`r - Jeo--/ <br />1868 E. Hazelton Avent./Je I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet Screen Feet <br />Slot Size: <br />remie gOther: e <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />Water <br />gallons <br />Cement 47 lb <br />Bags <br />Water <br />gallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest gBags Thickest Thinnest 11Bags <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 b 30 60 6 <br />17.5 35 7 35 70 7 <br />20 40 8 40 80 8 <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 />Date: Inspector: • <br />Facility Address <br />Well Address: <br />wp# 001-11 g 3 Well#: <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Geologist: <br />Consultant: <br />, Total Depth: <br />—ic)i-/EG4405 brilling Rig Type: <br />ri3 /4-06 Min 2" Annular EHD Seal Verified: <br />Screen Length From: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />CONSTRUCTION <br />Li Yes ON° <br />To: