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ON° <br />Screening Method: <br />Verified Chain of Custody: El Yes EINo <br />SPOILS <br />Contamination Noted: El Yes <br />If yes, spoils storage Location: <br />Ell Yes ON° Covered: <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: 75 I <br />Depth to Water: <br />Grout Material: NeA-- cvetAe vor , <br />Gallons of Grout Used: -3`5-06S/t( cyo <br />111 Well Installation 111 Well Destruction <br />Date: 2- Inspector: <br />Facility Address: .6‘ DOCW <br />Well Address: <br />VVP# CiA 210 <br />Soil Boring#: <br />Drilling Company: (7114'W,0,1 0 )1 1( <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />Public Water System Onsite: EYes 1=INo <br />Domestic Well Onsite: 111 Yes 11No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />ID Boring Installation IDBoring Destructio <br />METHOD USED <br />111Pressure Grout DOver Drill <br />LI Gravity 1110ther: <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: 111 Yes 1=INo <br />To: <br />To: <br />To: <br />To: <br />COMPLETION El Stove Pipe IIIChristie Box <br />casing <br />height <br />Grourxi Surt acs <br />CNA:STY-80X <br />COMPLETION <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />From: <br />From: <br />From: <br />From: <br />grout <br />ft <br /> ft <br />r1L 12js. <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 />stottad <br />secdon <br />Water <br />gallons <br />Cement 47 lb' <br />Ba <br />Water <br />gallons <br />Cement 94Ib <br />Bags <br />Thickest Thinnest /Bags Thickest Thinnest flags <br />2.5 5 1 • 5 10 1 <br />5 10 2 it 10 20 2 <br />7.5 15 3 • 15 30 3 <br />10 20 4 0 20 40 4 <br />12.5 25 5 • 25 50 5 <br />15 30 6 • 30 60 6 <br />17.5 35 7 • 35 70 7 <br />20 40 8 • 40 80 8 <br />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com <br />Well#: <br />.41 <br />SANJOAQUIN <br />COUNTY <br />Greatness g rows here <br />Monitoring Well/Soil Boring Inspection Report <br />Environmental Health Department <br />Ooddrilie.d 1 Q Spa' <br />0 <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