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SANJ0AQUIN <br />—C OU NTY <br />Greatness grows here. <br />Date: Z2 <br />Facility Address: <br />Well Add ess: <br />WP# D <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: CONSTRUCTION <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 />Well#: <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation ❑Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity )�reft- DOther: <br />Total Depth: <br />Cement 471bI <br />Baas <br />Water <br />wallons <br />Drilling Rig Type: <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />Min 2" Annular EHD Seal Verified: <br />❑ Yes ❑No <br />\ Screen Length <br />From: <br />To: <br />/1 Filter Pack <br />From: <br />To: <br />Bentonite <br />From: <br />To: <br />Grout <br />From: <br />To: <br />Water <br />allons <br />Cement 471bI <br />Baas <br />Water <br />wallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />Bags <br />Thickest Thinnest <br />N Bags <br />2.5 5 <br />1 <br />s <br />10 <br />1 <br />5 10 <br />2 <br />10 <br />20 <br />2 <br />7.5 15 <br />3 <br />15 <br />30 <br />3 <br />10 20 <br />4 <br />20 <br />40 <br />4 <br />12.5 25 <br />5 <br />15 <br />50 <br />5 <br />15 30 <br />6 <br />30 <br />60 <br />6 <br />17.5 35 <br />7 <br />35 <br />70 <br />7 <br />20 40 <br />8 <br />40 <br />80 <br />8 <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />ht <br />c#iR7srr-Box <br />CO&FLETION COWLEIMON <br />Ground sutac, <br />groat <br />ft. <br />fi. <br />ft. <br />= o <br />slot -ad = <br />s+c:on = 3 <br />. = I -W rack <br />x <br />tt.IF=IF8. <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/Cement 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 209 468-34201 F 209 464-0138 1 www.sicehd.com <br />