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SANiJ0A0UIN Environmental Health Department <br />—COUNTY <br />_ Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: VcJl 'inspector: v <br />Facility Address: <br />Well Address: �1)/?\ <br />WP# `�`� Well#: rJ i VX <br />Soil Boring#: ►��-°j <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: �0 <br />Public Water System Onsite: ❑ Yes VNo <br />No <br />Domestic Well Onsite: El Yes <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑No <br />SPOILS <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />❑ Yes ❑No <br />❑ Yes ❑No <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water:gk <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation /Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity Iremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />Rallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />4Bags <br />Thickest Thinnest <br />ttBags <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 />3D <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />12.5 1 <br />25 <br />5 <br />25 <br />V <br />14 <br />15 1 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 1 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 1 <br />40 <br />8 <br />40 <br />80 <br />8 <br />CONSTRUCTION <br />4 'A <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />COMPLETION <br />From: <br />From: <br />From: <br />From: <br />❑ Stove Pipe <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <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 3% 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 />