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SANsJ0AQUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />Public Water System Onsite: yJ Yes ❑No <br />Domestic Well Onsite: V�Yes ❑No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: y <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑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: 37 <br />Depth to Water: k <br />Grout Material: <br />Gallons of Grout Used: 600 v <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation 013oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ;2fTremie ❑Other: <br />Water <br />allons <br />Monitoring Well/Soil Boring Inspection Repor- <br />Cement 471b <br />Bas <br />Water <br />eallill ons <br />Date:..? a z.>z, <br />Inspector: <br />CONSTRUCTION <br />Facility Address: <br />-\-. <br />0-. ) <br />Well Address: <br />1 <br />Total Depth: <br />WP# pe v�-L� 'L� <br />Well#: t�Jl <br />Drilling Rig Type: <br />Soil Boring#: <br />Z Q- 3 <br />Min 2" Annular EHD Seal Verified: <br />Drilling Company: l5s� <br />&A <br />7.5 <br />Driller Onsite: <br />v� N5 V__1, <br />Screen Length From: <br />Consultant: p� <br />J C,"Q_ r <br />Filter Pack From: <br />Geologist: <br />Bentonite From: <br />40 <br />4 <br />Grout From: <br />Public Water System Onsite: yJ Yes ❑No <br />Domestic Well Onsite: V�Yes ❑No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: y <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑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: 37 <br />Depth to Water: k <br />Grout Material: <br />Gallons of Grout Used: 600 v <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation 013oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ;2fTremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />eallill ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br /># Bags <br />Thickest Thinnest <br />V Bags <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 />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />25 <br />50 <br />5 <br />15 <br />3 <br />i8d <br />30 <br />60 <br />6 <br />17.5 <br />3 <br />35 <br />70 <br />7 <br />20 <br />40 <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 />it. <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 />