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SAN 10AQUIN <br />-COUNTY <br />GIeo ness g,-Ovs here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspectio ` or <br />X30 <br />Date: / 2 2Zlnspector: V _ CONSTRUCTION <br />Facility Address:_ zt©[ . C OL c', <br />Well Address: — <br />WP# <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />Public Water System Onsite: <br />Domestic Well Onsite: <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 />-3 <br />❑ Yes ElNo <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: � �j <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 ❑Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />5% Mix <br />Water <br />allons <br />Cement 941b <br />ea s <br />Thickest <br />Thinnest <br />#Bags <br />4.7 <br />Thickest <br />Thinnest <br />#Bags <br />Z.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 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 <br />8 <br />Drilling Rig Type: � � � C �� <br />Min 2" Annular EHD Seal Verified: ❑Yes ❑No <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION ❑Stove Pipe ❑Christie Box <br />casing <br />height <br />ABOVE -G ROUND G#iRSS"TY-80X <br />COM?L MN comPLEnoN <br />Ground SurfaceAl <br />-- <br />n-- <br />APO <br />s . <br />if <br />its <br />3 <br />p <br />`sr� = � <br />=, �� Pack <br />3 <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 <br />n. <br />Feet <br />BentonitefOement Mix <br />3% Mix <br />5% Mix <br />Bentonite per 47 Ib <br />1.41 <br />2.47 <br />Bentonite per 94 Ib <br />2.82 <br />4.7 <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 <br />n. <br />Feet <br />BentonitefOement Mix <br />3% Mix <br />5% Mix <br />Bentonite per 47 Ib <br />1.41 <br />2.47 <br />Bentonite per 94 Ib <br />2.82 <br />4.7 <br />5� <br />10/16/2017 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sicehd.com <br />