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SAN 10AQUIN <br />------COUNTY <br />Greatness grows her.: <br />Facility Address: <br />Well Address: <br />WP# � <br />Soil Boring#: <br />Drilling Company: <br />Driller Ons <br />Consultant <br />Geologist: <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Inspector: VM <br />Well#: <br />CONSTRUCTION <br />^ � Total Depth: <br />��'`� � Drilling Rig Type: <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 />❑ Yes ❑ No <br />❑ Yes ❑No <br />Verified Chain of Custody: ❑Yes ❑No <br />cpnll c <br />Contamination Noted: ❑Yes ❑ No <br />If yes, spoils storage Location: <br />Covered: ❑Yes ❑ No <br />If yes, material: <br />GROUTING or�ESTRU <br />Depth to Water <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation <br />,Well Destruction <br />❑Boring Installation ❑Boring Destruction <br />METHOD USED <br />❑Pressure Grout Over Drill <br />�� <br />❑ Gravity � \remie ❑Other: <br />v�later� <br />allons <br />Cement 471b <br />Bas <br />5% Mix <br />S;Vater <br />oallons <br />Cernent 941b <br />Ba s <br />Thi�l;est <br />Thinnest <br />#Bags <br />4.7 <br />Tl�rickest <br />Thinnest <br />Bags <br />2.5 <br />S <br />1 <br />S <br />1Q <br />1 <br />s <br />10 <br />z <br />10 <br />zo <br />z <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />?U <br />40 <br />4 <br />12,5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />3tl <br />6 <br />3Q <br />60 <br />6 <br />1?.5 <br />35 <br />? <br />35 <br />7C1 <br />? <br />20 <br />ao <br />s <br />4o <br />so <br />s <br />��i <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />COMPLETION <br />❑ Yes ❑No <br />From: To: <br />From: To: <br />From: To: <br />From: To: <br />❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />ABOVE-GRG�tJND GNASS?Y-80X <br />COM�'L.ET}ON CC�#„iPLETICN <br />around Surfxa <br />prom <br />�t. <br />n. <br />tt, <br />:;� _ <br />�:, = � <br />h� — <br />;; -- p <br />— m <br />= c <br />.�.,. � Q <br />:tonQd _ � <br />argon - � <br />w� _ <br />��:- <br />ft. �� - 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 <br />Feet <br />BentonitefOement Mix <br />3% Mix <br />5% Mix <br />Bentonite per 4l Ib <br />1.41 <br />2.47 <br />Bentonite per 94 Ib <br />2.82 <br />4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sicehd.com <br />J <br />