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L1�1i - —COU NTY— <br />�;; = Gi-eatness grows here, <br />Environmental Health Department <br />Mogitor4V Well/Soil Boring Inspection Report <br />Date: k L-- Inspector: ( CONSTRUCTION <br />Facility Address: — 0rr <br />Well Address: ^/ - Total Depth: <br />WP# Z Well#:<A///) Drilling Rig Type: <br />Soil Boring#: Z <br />Drilling Company: ?,LH ZAA% • - A;�SDC Min 2" Annular EHD Seal Verified: <br />❑ Yes ❑ No <br />' Screen Length <br />Driller Onsite: i4 n / 1h <br />From: <br />To: <br />Filter Pack <br />Consultant: `2 ZAA,) <br />From: <br />To: <br />Geologist: Bentonite <br />From: <br />To: <br />Grout <br />From: <br />To: <br />Public Water System Onsite: <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING # <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody: <br />SPOILS <br />Contamination Noted <br />f�l Yes ❑No <br />(❑ Yes /No <br />❑ Yes ❑No <br />❑ 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: I 'tR -/1'0 <br />Grout Material: AleOr <br />Gallons of Grout Used: jy <br />❑Well Installation ❑Well Destruction <br />❑Boring InstallationI�Boring Destruction <br />METHOD USED Installation/ <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity /Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />Rall ons <br />Cement 941b <br />Bags <br />Thickest Thin,qRst <br />9B <br />Thickest Thinnest <br />ii Bags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />s V <br />10 20 <br />2 <br />7.5 15 <br />3 <br />15 30 <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 />8 <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />ABOVE -GROUND CHASSTY 30X <br />(2O&FiET)ON COMPtETioN <br />Q-cund Swfa a <br />grout <br />fi. <br />ack <br />-- o <br />st:sttgd - _ a <br />_ 7wtP <br />yw <br />= fi. <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 3% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.821 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 />