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r SAN :IOA0UIN <br />Environmental Health Department <br />—COU NTY— <br />_ ° Greatness grows here. <br />f." <br />Monitoring Well/Soil Boring Inspection Report <br />Date: /Z 20 Inspector: AL144 <br />Facility Address: k) ay rwA <br />Well Address: <br />WP# Well#: <br />Soil Boring#: ( 2 <br />Drilling Company; Vf <br />Driller Onsite: PYl j he <br />Consultant: A <br />Geologist:ji <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 />❑ Yes <br />❑ Yes <br />1�7 No <br />KNo <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />If yes, material: <br />t <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: t1JWt Wcder <br />Grout Material: N42ol fo iQ <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation 5&Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />Gravity ❑Tremie XOther: n4z/ <br />Water <br />gall s <br />Cement 471b <br />Bas <br />Water <br />g aIII III ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />k Bags <br />Thickest Thinnest <br />rlBags <br />15 <br />5 <br />1 <br />5 10 <br />1 <br />5 <br />10 <br />2 <br />10 20 <br />2 <br />7.5 <br />15 <br />3 <br />15 30 <br />3 <br />10 <br />20 <br />4 <br />20 40 <br />4 <br />25 <br />n <br />25 50 <br />5 <br />30 <br />6 <br />30 60 <br />6 <br />17.5 <br />35 <br />7 <br />35 70 <br />7 <br />20 <br />40 <br />8 <br />40 80 <br />8 <br />CONSTRUCTION 04 <br />Total Depth: _ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length From: <br />Filter Pack From: <br />Bentonite From: <br />Grout From: <br />COMPLETION ❑ Stove Pipe <br />❑ Yes []No, <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />TVcasing <br />height <br />ABOVE-GRCUND <br />COWL ETION C rRZ Y -Box <br />COMPLETION <br />Ground SuPacs <br />grout <br />_ o <br />O <br />slotted <br />ssclon _ <br />I � - _ Gtzval Pack <br />tt. <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/Gement 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 />