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SAN.IOAQUIN <br />—COUNTY— <br />_ Greatness grows here, <br />Environmental Health Department <br />Public Water System Onsite: /Yes El No <br />Domestic Well Onsite: ❑ Yes /No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes El No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: / <br />Depth to Water: k W 604 <br />Grout Material: <br />Gallons of Grout Used: Y' loD A <br />❑Well Installation ❑Well Destruction <br />❑Boring installation�Boring Destruction <br />nnFTunn I KIM <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �Tremie ❑Other: <br />Water <br />allons <br />Monitoring Well/Soil Boring Inspection Repor! <br />Water <br />Rallons <br />Cement 941b <br />Bao <br />Date: I MAt���' <br />Inspector: <br />CONSTRUCTION <br />Facility Address: I y , <br />2N&'iv���r�/a <br />Well Address: <br />4,1 Zfi <br />Total Depth: <br />WP# L4'L-1% <br />Well#: /Ll I <br />Drilling Rig Type: <br />Soil Boring#: <br />Drilling Company: <br />Z Gt 2 <br />(, � <br />Min 2" Annular EHD Seal Verified: <br />3 <br />15 <br />30 <br />Driller Onsite: <br />�, <br />Screen Length From: <br />Consultant: CgAyj <br />r(o_� L. <br />Filter Pack From: <br />^n q <br />Geologist: /'' <br />�, rA <br />Bentonite From: <br />50 <br />5 <br />Grout From: <br />Public Water System Onsite: /Yes El No <br />Domestic Well Onsite: ❑ Yes /No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes El No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: / <br />Depth to Water: k W 604 <br />Grout Material: <br />Gallons of Grout Used: Y' loD A <br />❑Well Installation ❑Well Destruction <br />❑Boring installation�Boring Destruction <br />nnFTunn I KIM <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />Rallons <br />Cement 941b <br />Bao <br />Thickest Thinnest <br />NB s <br />Thickest Thinnest <br />#Bags <br />2.5 5 <br />5 <br />10 <br />1 <br />5 0 <br />2 <br />10 <br />20 <br />2 <br />7.5 15 <br />3 <br />15 <br />30 <br />3 <br />10 20 <br />4 <br />20 <br />40 <br />4 <br />12.5 25 <br />5 <br />25 <br />50 <br />5 <br />15 30 <br />6 <br />30 <br />60 <br />6 <br />17.5 35 <br />7 <br />35 <br />70 <br />7 <br />2D 40 <br />8 <br />40 <br />80 <br />8 <br />COMPLETION ❑ Stove Pipe <br />❑ Yes ❑ No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />tt. <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 209 468-34201 F 209 464-0138 1 www.sicehd.com <br />