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SAN JOAQUIN <br />C <br />V);<' FJ�y=; COUNTY <br />Greatness grows here. <br />Date:- d / b / oC. <br />Facility Address:_ <br />Well Address: <br />wP# DD <br />Soil Boring#: A, <br />Drilling Company: <br />Driller OnsitQ• <br />Consultant <br />Geologist: <br />Environmental Health Department <br />Monitoring well/ oil Boring Inspection Report <br />_ Inspector � <br />or: ?�l <br />/� 0^ C J/w <br />Well#: <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 <br />❑No <br />❑Yes ❑ No <br />O <br />CONSTRUCTIN <br />Total Depth: <br />n Drilling Rig Type. <br />r r 6 Min 2" Annular EHD Seal Verified: <br />❑Yes ❑No <br />Screen Length From: To: <br />Filter Pack From: To. <br />Bentonite From: To. <br />Grout From: To. <br />COMPLETION <br />❑ Yes ❑ No <br />a y 6 <br />� t <br />GROUTING or DESTRUCTION Total Depth:��Sl <br />Depth to Water: '`' � y <br />Grout Material: <br />Gallons of Grout Used: 0 fi CJ <br />[]Well <br />Installation ❑Well Destruction <br />:]Boring Installation`r$6 <br />oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />.jGravity ?sL <br />remie ❑Other: <br />Water Ceme t 471b Water Cement 941b <br />gallons ea all <br />�3 <br />❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />a►BovEmsGROUND cHwssn-aox <br />COMPLETION COMPLETION <br />Ground Surlacs + <br />------ <br />grout <br />h. <br />fi. <br />ft. <br />4-s <br />40 <br />_ O <br />stottad ... � <br />sacaon <br />gmv%4 Puck <br />:A — <br />. = An. <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 />BentonitefCement Mix <br />3°J° Mix <br />�°l° Mix <br />ons <br />Ba s <br />Thickest <br />Thinnest <br />#Bags <br />2.82 <br />Thickest <br />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 <br />40 <br />8 <br />40 <br />80 <br />8 <br />�3 <br />❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />a►BovEmsGROUND cHwssn-aox <br />COMPLETION COMPLETION <br />Ground Surlacs + <br />------ <br />grout <br />h. <br />fi. <br />ft. <br />4-s <br />40 <br />_ O <br />stottad ... � <br />sacaon <br />gmv%4 Puck <br />:A — <br />. = An. <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 />BentonitefCement Mix <br />3°J° Mix <br />�°l° Mix <br />Bentonite per 47 Ib <br />1.41 <br />2.47 <br />Bentonite <br />per 94 Ib <br />2.82 <br />4.7 <br />1868 E. Hazelton Avenue Sto on, California 95205 T 209 468-3420 <br />10/16/2017 <br />F 209 464-0138 � www.sicehd.com <br />