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SAN.AAWN COUNTY Environmental Health Department Monitoring Well/Soil Boring Inspection Report Date: -011VIlk Inspector: X�' Facility Address: �,c,�,nt Well Address: WP# 00 'k 1Z 0 I Well#: Soil Boring#: 'L ' '1A Drilling Company: U Yrt4 Driller Onsite: Consultant: N Geologist: siJ, Public Water System Onsite: ❑ Yes El No Domestic Well Onsite: If yes, location and distance: SAMPLING Holding Temperature: Method: Screening Method:_ Verified Chain of Custody Contamination Noted: If yes, spoils storage Location: ❑ Yes ❑No ❑ Yes ❑ No ❑ Yes ❑ No Covered: ❑ Yes ❑ No If yes, material: GROUTING or DESTRUCTION Total Depth: Depth to Water: IL t' Grout Material: Gallons of Grout Used: ❑Well Installation ❑Well Destruction ❑Boring Installation tgBoring Destruction METHOD USED ❑Pressure Grout ❑Over Drill ❑ Gravity Premie ❑Other: Water allons Cement 471b Bags Water gallons Cement 941b Bags Thickest Thinnest 9Bags Thickest Thinnest #Bags 2.5 5 1 5 10 1 5 10 2 10 20 2 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 CONSTRUCTION Total Depth: Drilling Rig Type: Min 2" Annular EHD Seal Verified: ❑ Yes El No Screen Length From: To: Filter Pack From: To: Bentonite From: To: Grout From: To: COMPLETION ❑ Stove Pipe ❑Christie Box casing height ABOVE -GROUND CHRMTY43OX COMPLETION COMPLETION Ground Surfw* + grout tt. ft. sic s�c3on pravol pack tL F= ft. MATERIALS/DEVELOPMENT Casing Type: Blank Feet Slot Size: Bags of Cement: Bags Sand/Gravel: Type/Brand of Bentonite: Filter Pack Type/Size: Type of Method: Screen Feet BentonitelCement Mix 3% Mix 5% Mix Bentonite per 47 Ib 1 1.411 2.47 Bentonite per 94 Ib 1 2.821 4.7 10/16/2017 1868 E. Hazelton Avenue�tockton alifornia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com