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SAN 10AQUIN <br />----COUNTY ----- - <br />V7�tL�tii�SS t310Y7�S t7E1��::. <br />Date: �'� <br />Facility Address: <br />Well Address: <br />WP# <br />Soil Boring#: <br />Drilling Company: � <br />Driller Onsite: <br />Consultant <br />Geologist: <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Inspector: <br />� � �� <br />Well#: <br />0 Ck� <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 />❑ Yes ❑ No <br />❑ Yes ❑No <br />CONSTRUCTION <br />�I'r,� <br />Total Depth: _ <br />Drilling Rig Type: <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth:_��� . <br />Depth to Water: <br />Grout Material: P � �(fl/�Vl:< <br />Gallons of Grout Used: ����� <br />�1Well Installation ❑Well Destruction <br />❑Boring Installation ❑Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity <br />❑Tremie <br />.�� <br />❑Other: <br />VVater <br />gallons <br />ema_nt 471 <br />Ba4s <br />5% Mix <br />b�+ater <br />gallons <br />Cement 941b <br />Bags <br />Thickest <br />Thinnest <br />„Bags <br />4.7 <br />Thickest <br />Tl��innest <br />� Bags <br />2.5 <br />5 <br />1 <br />S <br />10 <br />1 <br />S <br />1U <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <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 />30 <br />60 <br />6 <br />15 <br />30 <br />6 <br />35 <br />i0 <br />7 <br />1i.S <br />35 <br />7 <br />40 <br />80 <br />8 <br />20 <br />40 <br />8 <br />Min 2" Annular EHD Seal Verified: ❑Yes ❑No <br />Screen Length From: To: <br />Filter Pacl< From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION ❑Stove Pipe Christie Box <br />:. - .. <br />.. <br />�.. <br />.. <br />��. - <br />ft. <br />��� - <br />,,; <br />5 s to tied �. <br />sQcon <br />�. <br />:�: <br />a. <br />it. <br />MATERIALS/DEVELOPMENT <br />Casing Type: C, <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 />��� <br />Screen__ Feet <br />Bentonite/Cement 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 />10/16/2017 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sicehd.com <br />