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SAN 10AQUIN <br />COUNTY— <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Yes ❑No <br />Verified Chain of Custody: ❑ Yes El No <br />SPOILS <br />Contamination Noted: ❑ Yes �No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes f 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 f Boring Destruction <br />nnrTunn i 1Crn <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity [�Tremie ❑Other: <br />Water <br />allons <br />Monitoring Well/Soi <br />Date: IR hth <br />Inspector: `./n�, kuy.-Ik� <br />Facility Address:l65 <br />-7r.-4nf L)me <br />Well Address: <br />#Bags <br />WP# OD9,2 :7 FC t <br />Well#: <br />Soil Boring#:g <br />s <br />Drilling Company: LacD)�ra�fJ1��-�eoSer��te� <br />s <br />Driller Onsite: <br />1 <br />Consultant: <br />10 <br />Geologist: S <br />10 <br />20 <br />2 <br />Public Water System Onsite: ❑ Yes �No <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Yes ❑No <br />Verified Chain of Custody: ❑ Yes El No <br />SPOILS <br />Contamination Noted: ❑ Yes �No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes f 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 f Boring Destruction <br />nnrTunn i 1Crn <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity [�Tremie ❑Other: <br />Water <br />allons <br />From: <br />Cement 471b <br />Bas <br />Water <br />vall ons <br />From: <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />#Bags <br />Thickest Thinnest <br />xBags <br />2.5 <br />s <br />1 -- <br />s <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 1 <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: — <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑ Yes 11 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 />casing <br />height <br />ABOVE -GROUND CHRMTY-sox <br />CONPL ETION COMPLETION <br />cf«md sorra .+ <br />grout <br />T fit. <br />ft. <br />wp: G <br />e <br />s <br />C <br />sicttnd <br />1K'J4n - -- <br />lit <br />Y. <br />A <br />ft, <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/Gement 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 />