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SANS,JOAQUIN <br />—COUNT Y— <br />�' Grectness gro-ws here. <br />Date: (11-1-1 ( 0 <br />Facility Address: <br />Well Address: <br />W P# Z <br />Soil Boring#: Vw, <br />Drilling Company: 1 <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Inspector: " <br />M CONSTRUCTION <br />)otal Depth: <br />Well#: �- Drilling Rig Type: <br />Public Water System Onsite: ❑ Yes 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 Custod ` ❑ Yes ❑No <br />SPOILS <br />Contamination ted: <br />If yes, spoi storage Location: <br />Cover/ed.- <br />If <br />overed• <br />If y , material: <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />i <br />GROUTING or DESTRUCTION Total Depth: , <br />Depth to Water: - 14 <br />Grout Material: A)w /11/'141T <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />El Boring Installation �Boring Destruction <br />METHOD USED <br />❑Pressure Grout❑Over Drill <br />❑ Gravity L(ITremie ❑Other: <br />Water <br />gallons <br />From: <br />Cement 471b <br />Bas <br />Water <br />Raill ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />ttBags <br />Thickest Thinnest <br />4Bags <br />2.5 <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 />12.5 <br />25 <br />5 <br />25 50 <br />5 <br />15 <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 />a <br />Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br />Screen Length <br />From: <br />To: <br />Filter Pack <br />From: <br />To: <br />Bentonite <br />From: <br />To: <br />Grout <br />From: <br />To: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />M <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 />BentoniteXement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />i <br />4- �a+ W 30 ✓�/1 UDPJ (1,{ J 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 />