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SAN JOAQUIN <br />—COUNTY— <br />Greatness grows he--. <br />Public Water System Onsite: ❑ Yes ❑No <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 />conn c <br />Contamination Noted: ❑ Yes ll7N <br />If yes, spoils storage Location: <br />Covered: ❑ Yes 2�1\lo <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 flBoring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity XTremie ❑Other: <br />Water <br />alIII ons <br />Monitoring WL�'"ell/Soi <br />Date: I J d <br />Inspector: c RuY�1 C fIwt <br />Facility Address: _ 1(_1 <br />L Ae— <br />Well Address: <br />#Bags <br />WP#--&� O()ga%a <br />Well#: <br />Soil Boring#: -t <br />5 <br />Drilling Company: <br />l"e -s <br />Driller Onsite: %ics <br />Consultant: <br />5 <br />Geologist:'�� <br />2 — <br />Public Water System Onsite: ❑ Yes ❑No <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 />conn c <br />Contamination Noted: ❑ Yes ll7N <br />If yes, spoils storage Location: <br />Covered: ❑ Yes 2�1\lo <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 flBoring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity XTremie ❑Other: <br />Water <br />alIII ons <br />From: <br />Cement 471b <br />Bas <br />Water <br />lZallons <br />From: <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />#Bags <br />Thickest Thinnest <br />#Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 — <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 />12.5 <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 <br />8 <br />Environmental Health Department <br />Boring Inspection Report <br />CONSTRUCTION <br />Total Depth: E' ' <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑ Yes El No <br />Screen Length <br />From: <br />To: <br />Filter Pack <br />From: <br />To: <br />Bentonite <br />From: <br />To: <br />Grout <br />From: <br />To: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <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 />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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />