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SAN:J0A0UIN <br />—COUNTY— <br />Greainess grows here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Repor <br />Public Water System Onsite <br />Domestic Well Onsite: <br />If yes, location and distant <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody: <br />SP@ILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />115 Yes ❑No ('Q V-1\pCOMPLETION ❑ Stove Pipe <br />❑ Yes CN 0 <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />❑ Yes []No <br />GROUTING or DESTRUCTION Total Depth:3o <br />Depth to Water: x 2S' <br />Grout Material: 1Jj(Jp.� <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation /Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity kremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Date: <br />Inspector: CONSTRUCTION <br />Facility Address:V���IC-� <br />s <br />Well Address: <br />Total Depth: <br />WP# �L. <br />Well#: Drilling Rig Type: <br />Soil Boring#: <br />L <br />Drilling Company:�p�J� <br />Min 2" Annular EHD Seal Verified: <br />10 20 <br />�rK�. \A <br />Driller Onsite: <br />n Screen Length From: <br />(/� /3 RIter Pack From: <br />Consultant: �� b,, <br />y�� �� r <br />Geologist: <br />_ Bentonite From: <br />-O <br />20 40 <br />Grout From: <br />Public Water System Onsite <br />Domestic Well Onsite: <br />If yes, location and distant <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody: <br />SP@ILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />115 Yes ❑No ('Q V-1\pCOMPLETION ❑ Stove Pipe <br />❑ Yes CN 0 <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />❑ Yes []No <br />GROUTING or DESTRUCTION Total Depth:3o <br />Depth to Water: x 2S' <br />Grout Material: 1Jj(Jp.� <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation /Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity kremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />allons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />s <br />Thickest Thinnest <br />#Bags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 ir <br />10 20 <br />2 <br />7.5 15 <br />3 <br />15 '0 <br />3 <br />10 20 <br />4 <br />20 40 <br />4 <br />12.5 25 <br />5 <br />25 50 <br />5 <br />15 30 <br />6 <br />30 60 <br />6 <br />17.5 35 <br />7 <br />35 70 <br />7 <br />20 40 <br />8 <br />40 80 <br />a <br />❑ Yes ❑ No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />casing <br />height <br />ABOVE -GROUND c ia>m Sox <br />CONFLECION COMPLETION <br />Ground surto <br />proof <br />tt. <br />ft. _ <br />— o <br />slotted - <br />saaion -- — <br />.. _ qmv&A tack <br />K. <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 />Screen Feet <br />BentoniteXement 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 />