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SAN 1UAUUIN <br />1 141'm` / - COUNTY— <br />ogPJ Greatness grows here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: X02 L Inspector: �( -1L <br />FacilityAddress:_�_ �;,r 3N, �o�,` ✓� <br />Well Address: <br />W P# t ;Y) `t `)- 00\ Well##.: <br />Soil Boring#: n <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: ; G <br />Public Water System Onsite: ❑ Yes El No <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 />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: X' - <br />Grout Material: /)tk � f 0, t �. <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation VBoring Destruction <br />nnrTunn I [Crn <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity XTremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />Rallons <br />Cement 941b <br />Ba s <br />Thickest Thinnest <br />NBags <br />Thickest Thinnest <br />ltBags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 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 0 <br />7 <br />20 40 <br />8 <br />40 1 80 <br />8 <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑ Yes Ll 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 C4-(RIM430X <br />COMPLET{ON COMPLETICN <br />Ground Surian T <br />Grout <br />n. <br />n. <br />= o <br />— o <br />sbtt&d = 8 <br />a�cCon <br />n.I F=IFn. <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 I Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />