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SAN J 0 A 0 U I N <br />—COUNTY— <br />. <br />G-eoine-s grows Sere. <br />4._ <br />Environmental Health Department <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 />SPOILS C1\� <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes YJN0 <br />❑ Yes El No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: XM <br />Depth to Water: ir;OQ� <br />Grout Material: %'-P+t <br />Gallons of Grout Used: —1 A10 <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation V�Boring Destruction <br />nAFTunr) I ICFr1 <br />El Pressure Grout ❑Over Drill <br />❑ Gravity kremie ❑Other: <br />Water <br />allons <br />Monitoring Well/Soil Boring Inspection Repor- <br />Water <br />gallons <br />Cement 94 lb <br />Baps <br />Date: <br />Inspector: CONSTRUCTION <br />Facility Address: <br />#Bags <br />Well Address: <br />k Total Depth: <br />WP# y'���-\ <br />Well#: Drilling Rig Type: <br />Soil Boring#: <br />0\ `\ Min 2" Annular EHD Seal Verified: <br />'yVw\' SSW <br />Drilling Company: <br />������ � <br />Driller Onsite:.��Q�� <br />Screen Length From: <br />Consultant: <br />}-�Q�� Filter Pack From: <br />_��'Q.�1�1� <br />Geologist: <br />Bentonite 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 />SPOILS C1\� <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes YJN0 <br />❑ Yes El No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: XM <br />Depth to Water: ir;OQ� <br />Grout Material: %'-P+t <br />Gallons of Grout Used: —1 A10 <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation V�Boring Destruction <br />nAFTunr) I ICFr1 <br />El Pressure Grout ❑Over Drill <br />❑ Gravity kremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 94 lb <br />Baps <br />Thickest Thinnest <br />it Bags <br />Thickest Thinnest <br />#Bags <br />2.5 <br />5 10 <br />1 <br />s 10 <br />2 <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 1 70 <br />7 <br />2D 40 <br />8 <br />40 1 80 <br />8 <br />Grout <br />rnMDl FTInN <br />From: <br />❑ Stove Pipe <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <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 />Benton iteXement 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 />