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SAN: JOAQUIN r.; —COUNTY— Environmental Health Department ❑ Yes ❑ No To: To: To: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes El No If yes, location and distance: SAMPLING Holding Temperature: Method: Screening Method: Verified Chain of Custody: Cp()Il C Contamination Noted If yes, spoils storage Location: Covered: If yes, material: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑No GROUTING or DESTRUCTION Total Depth:_ Depth to Water: 12� I Grout Material: Gallons of Grout Used: ; ❑Well Installation ❑Well Destruction ❑Boring Installation .Boring Destruction METHOD USED ❑Pressure Grout ❑Over Drill ❑ Gravity K,lremle ❑Other: Water allons Monitoring Well/Soil Boring Inspection Report Water Rall ons Cement 94 lb Bags Ct�AIVIO0 sf8 Date: Inspector: ) ' CONSTRUCTION Facility Address: 100tO S, CeNmri k Mw �/ Well Address:_�Olk 2 7.5 15 \i; 1A`Total Depth: WP# 0 3 Well#: Drilling Rig Type: Soil Boring#: 4 12.5 25 5 Drilling Company: ; j Q_� 15 30 Min 2" Annular EHD Seal Verified: Driller Onsite: 6 17.5 35 Screen Length From: Consultant: — (j� �' -5 Filter Pack From: Geologist: ---E 11"1 8 Bentonite From: Grout From: ❑ Yes ❑ No To: To: To: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes El No If yes, location and distance: SAMPLING Holding Temperature: Method: Screening Method: Verified Chain of Custody: Cp()Il C Contamination Noted If yes, spoils storage Location: Covered: If yes, material: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑No GROUTING or DESTRUCTION Total Depth:_ Depth to Water: 12� I Grout Material: Gallons of Grout Used: ; ❑Well Installation ❑Well Destruction ❑Boring Installation .Boring Destruction METHOD USED ❑Pressure Grout ❑Over Drill ❑ Gravity K,lremle ❑Other: Water allons C t 471 Bas Water Rall ons Cement 94 lb Bags Thickest Thinnest sf8 Thickest Thinnest ttBags 2.5 5 ow 5 10 1 5 10 2 10 20 2 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 casing height ABOVE-GRWND CHRIS -TY -BOX COMPLETION COMPLETION Ground sumac. —+---- proof ft. it. ft. = o slotud 'c ast9on in _�+ * ft. = h. MATERIALS/DEVELOPM ENT Casing Type: Blank Feet Slot Size: Bags of Cement: Bags Sand/Gravel: Type/Brand of Bentonite: _ Filter Pack Type/Size: Type of Method: Screen Feet Bentonite/Cement Mix 3% Mix 3% Mix Bentonite per 47 Ib 1.411 2.47 Bentonite per 94 Ib 2.821 4.7 10/16/2017 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sicehd.com