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SAN 1 0A Q UIN <br />� Environmental Health Department <br />—COUNTY— <br />`} Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: �� ��'�' Inspector: <br />Facility Address: <br />Well Address: VVJ`k, `J S • '� <br />WP# �-ka`LI`V'l. Well#: <br />Soil Boring#: 71 <br />Drilling Company: CN:L�(� <br />Driller Onsite: v� NYr-- <br />Consultant: %�\�SUS�Jti his <br />Geologist: Sk!:!,- <br />Public Water System Onsite: ❑ Yes (No <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 />SPOILS <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth: A\ . s <br />Depth to Water: \'1` <br />Grout Material: N SSC 1P.� <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation koring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity OTremie ❑Other: <br />CONSTRUCTION <br />W �' <br />Total Depth:_ <br />Drilling Rig Type: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />eallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />#Bags <br />Thickest Thinnest <br />#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 />4 <br />20 <br />40 <br />4 <br />12,5 <br />15 <br />5 <br />25 <br />50 <br />5 <br />30 60 <br />6 <br />17.5 <br />35 <br />w <br />35 <br />70 <br />7 <br />2D <br />40 <br />B <br />40 <br />so <br />B <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 />casing <br />height <br />ABOVE-dROUND cHRmTY-BOX <br />COMPLETION CCUPLETiON <br />Ground Swfacs <br />grout <br />fi. <br />tt. <br />ft. <br />w <br />slatted ' <br />sac5on E _ <br />= tt. <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/Gement 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 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />