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SAN JOAQUIN <br />Environmental Health Department <br />—COUNTY <br />? - Greotness gro:,s !orre. <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: <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 />❑ Gravitye TTremie ❑Other: <br />Water <br />gallons, <br />Monitoring�Well/Soil Boring Inspection Report <br />Date: 901211 Inspector: <br />& (` <br />�`�' / <br />Water <br />aallons <br />Cement 94 lb <br />Bags <br />Q CONS MUC_I_ION <br /># Bags <br />Facility Address: 7, 2-co"""��```� <br />,) <br />j <br />2.5 <br />Well Add s: <br />Z�"°-6 btal Depth: ,530 <br />7ytJ <br />V G (-v, <br />WP# 00 <br />Well#: Drilling Rig Type: <br />I <br />Soil Boring#: <br />2 <br />10 <br />Drilling Company: '( <br />Min 2" Annular EHD Seal Verified: <br />❑ Yes ❑No <br />Driller Onsite: <br />Screen Length From: <br />To: <br />Consultant: <br />Filter Pack From: <br />To: <br />Geologist: <br />Bentonite From: <br />To: <br />40 <br />Grout From: SO/ <br />To: C)7— <br />Public Water System Onsite: <br />❑ Yes El No COMPLETION ❑ Stove Pipe <br />❑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: ❑ 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: <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 />❑ Gravitye TTremie ❑Other: <br />Water <br />gallons, <br />Cement 471b <br />Bas <br />Water <br />aallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br /># Bags <br />Thickest Thinnest <br />"ags <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 />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 1 <br />30 1 <br />6 <br />30 <br />60 <br />6 <br />17.5 1 <br />35 1 <br />7 <br />35 <br />70 <br />7 <br />20 1 <br />40 1 <br />8 <br />1 40 <br />80 <br />8 <br />casing <br />height <br />AWVE-GROUND c418isri-Box . <br />COLFLE MN COMPLETiON <br />c�rocsrsa s�tx, <br />grout <br />tt_ <br />µ O <br />_ — o <br />aicttQd <br />sac sen —' <br />= Brawl pads <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 Mix3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />t <br />10/16/2017 <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />