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SAWAAHIN <br />—COUNTY <br />Greotlicss <br />COUNTY <br />Greotuess gro•r+s fere. <br />Environmental Health Department <br />% Monitoring�/Well/Soil Boring Inspection Report <br />Date: s Z 2Z Inspector: S Ul / CONSTRUCTION <br />Facility Address: 100 CIC- <br />Well <br />IC -Well Addres : Total Depth: <br />WP# 0 U Well#: Drilling Rig Type: <br />Soil Boring#: — Min 2" Annular EHD Seal Verified: <br />Drilling Company: rLA b e <br />❑ Yes ❑No <br />Driller Onsite: Screen Length From: To: <br />Consultant: 17c i M -F t�V Filter Pack From: To: <br />Geologist: Bentonite From: To: <br />Grout From: To: <br />Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <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: <br />,,pnrl c <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: 150/ <br />Depth to Water: 2 <br />Grout Material 22 el - �.. <br />Gallons of Grout Used: — o— <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation ring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �1 -remie ❑Other: <br />Water <br />gallons <br />Cement 47lb <br />Bas <br />Water <br />Rajlons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />4 Bags <br />Thickest Thinnest <br />r Bags <br />2.5 <br />5 <br />1 <br />5 10 <br />1 <br />5 <br />10 <br />2 <br />10 20 <br />2 <br />7.5 <br />15 <br />3 <br />15 30 <br />3 <br />10 <br />20 <br />4 <br />20 40 <br />4 <br />12.5 <br />25 <br />5 <br />25 50 <br />5 <br />15 <br />30 <br />6 <br />30 60 <br />6 <br />17.5 <br />35 <br />7 <br />35 70 <br />7 <br />20 <br />40 1 <br />8 <br />40 80 <br />8 <br />T casing <br />height <br />T <br />T <br />ABOVE-GRCiJND CHRls-N-BOX <br />CO W L=TIO N COMPL-i70TJ <br />Ckour4 SLwfacs <br />pracrt <br />ft. <br />tt. <br />rt. <br />— p <br />— a <br />_R• � C <br />O <br />SIOt?.Qd — <br />.� — <br />ss�on <br />_ _rrarvl pack <br />ft. = n. <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 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />