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SANAAQUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />Depth to Water: <br />Grout Material: <br />Covered: <br />If yes, material: <br />ii 1, / <br />GROUTING or DESTRUCTION Total Depth: r tJ <br />g( t u 72 ,A,r ceri <br />oring Destruction EBoring Installation <br />METHOD USED <br />111 Gravity 3 tremie E0ther: <br />Monitoring Well/Soil Boring Inspection Report <br />Date: LI /3(7'7' Inspector: CONSTRUCTION <br />Facility Address: 6'/7 IAT , L; )11 <br />, <br />-ca-7 3tt\- <br />Well Address: <br />WP# 00 143 1 Well#: <br />Soil Boring#: SDI _ <br />Drilling Company: Coc,..S1 up\ <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />Public Water System Onsite: El Yes ON° <br />Domestic Well Onsite: E Yes 111 No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: IEI Yes ENo <br />SPOILS <br />Contamination Noted: E Yes ENo <br />If yes, spoils storage Location: <br />Gallons of Grout Used: <br />OWell Installation OWell Destruction <br />El Pressure Grout EOver Drill <br />Water <br />gallons <br />Cement 47Ib <br />Bags <br />Water <br />gallons <br />Cement 94Ib <br />Bags <br />Thickest <br />2.5 <br />Thinnest <br />5 <br />it Bags <br />1 <br />Thickest <br />5 <br />Thinnest <br />10 <br />it Bags <br />1 <br />5 10 2 10 20 2 <br />7.5 15 3 15 30 a <br />10 N 4 M 4 4 <br />12.5 25 5 M M 5 <br />n n 6 M 60 6 <br />17.5 M 7 M M 7 <br />N 40 8 40 80 8 <br />COMPLETION Ei Stove Pipe EChristie Box <br />ft. <br />casing <br />height <br />.— <br />A5014E-GROUND <br />COMPLETION ansri--pox - <br />ccimetEnpN <br />grout <br />4r ft <br />ft <br />Grocind Surfacir <br />—ft <br />slotted <br />virclon <br />ftl <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/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 lb 1.41 2.47 <br />Bentonite per 94 lb 2.82 4.7 <br />10/16/2017 <br />Yes ElNo <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: E Yes ENo <br />To: <br />To: <br />To: <br />To: <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />From: <br />From: <br />From: <br />From: