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t SANIJOAQUIN <br />, - _ <br />—COUNTY— <br />Greatness grows here <br />Environmental Health Department <br />Monitoring4� <br />Well/Soil Boring Inspection Report <br />( <br />Date: `'��0�� Inspector: b�CONSTRUCTION <br />Facility Address: rl,oQ> �Z-0' <br />Well Address: t , Total Depth: <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#:Z]D' (o' 2. <br />Drilling Company: Min 2" Annular EHD Seal Verified: <br />`\ Screen Length From: <br />Driller Onsite: Y'c Filter Pack From: <br />Consultant: <br />Geologist: ��j� Bentonite From: <br />Grout From: <br />Public Water System Onsite: 1A Yes El 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 />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth:_ <br />Depth to Water: `Q <br />Grout Material: VI) FSI n <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destructio <br />❑Boring Installation q <br />Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity 4Tremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Ba s <br />Thickest Thinnest <br />uBags <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 />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 1 <br />10 <br />CE <br />40 1 <br />80 <br />8 <br />COMPLETION ❑ Stove Pipe <br />❑ Yes El No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />ft. <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 5% 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 />