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_��;`��i;� SAN JUAUUIN <br />��'` `, —COUNTY <br />��tiioa>P� Grza:n ss grove, oei: <br />Environmental Health Department <br />MonitoringJjWell/Soil Boring Inspection Report <br />Date: (�-t- Inspector: I'w CONSTRUCTION <br />Facility Address: <br />Well Address: <br />WP# e g Well#: <br />Soil Boring#: - C <br />Drilling Company: <br />Driller Onsite: <br />Consultant:Z` <br />Geologist: —r <br />Public Water System Onsite <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />From: <br />Filter Pack <br />From: <br />Bentonite <br />From: <br />Grout <br />From: <br />❑ Yes L-1 No COMPLETION ❑ Stove Pipe <br />❑ Yes ❑No <br />Verified Chain of Custody: ❑ Yes ❑No <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />❑ Yes ❑No <br />Covered: ❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth:'✓ <br />Depth to Water: wi' � <br />Grout Material: iV k,A <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation WBoring Destruction <br />nnGTWnn i icGn <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity f Tremie ❑Other: <br />Water <br />gallons <br />3% Mix <br />Cement 471b <br />Bas <br />Water <br />Rall ons <br />1.41 <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />pBags <br />Thickest Thinnest <br />PBags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />Q <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 <br />8 <br />❑ Yes ❑ No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />MATERIALS/DEVELOPM ENT <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/ ement Mix <br />3% Mix <br />5% Mix <br />Bentonite per 47 Ib <br />1.41 <br />2.47 <br />Bentonite per 94 Ib <br />2.82 <br />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 />