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f�Pu` <br />:-ter <br />SAN JOAQUIN <br />t��. —COUNTY <br />Greatness grows her( <br />Environmental Health Department <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑ No <br />r,pnll q <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation�eoring Destruction <br />METHOD USED // \\ <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ❑Tremie ❑Other: <br />Water <br />allons <br />Monitoring Well/Soil Boring Inspection Report <br />Cement 471b <br />Bas <br />Water <br />gallons <br />5 Z <br />Thickest T innest <br />9Bags <br />Date: Inspector: <br />Ul <br />CONSTRUCTION <br />Facility Address: `1� ___7> �72 <br />1 <br />5 <br />Well Address: <br />1 <br />Total Depth: <br />WP# lam'/? Z , ' We It: <br />Drilling Rig Type: <br />Soil Boring#: -l- <br />Drilling Company: <br />" <br />L S <br />Min 2" Annular EHD Seal Verified: <br />Driller Onsite: <br />rn _e. <br />Screen Length From: <br />Consultant: <br />G <br />Filter Pack From: <br />Geologist: C <br />;,,x p I <br />Bentonite From: <br />20 <br />40 <br />Grout From: <br />Public Water System Onsite: <br />❑ Yes El No <br />COMPLETION ❑ Stove Pipe <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑ No <br />r,pnll q <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation�eoring Destruction <br />METHOD USED // \\ <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ❑Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest T innest <br />9Bags <br />Thickest Thinnest <br />itBags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />102 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12S <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 1 <br />8 <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />casing <br />height <br />ABOVE -GROUND CJ RZTY43OX <br />OCWLET1ON COMPLE71CN <br />Ground Surtact If <br />grout <br />ft. <br />tt. <br />ft. <br />= m <br />= m <br />— o <br />abttnd = � <br />sac:cn _ <br />I= R=+s1 Pac.(c <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />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 />n. <br />Screen Feet <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />