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SAN 1UAUUIN <br />COUNTY— <br />Greatness grows herr. <br />Date: 2 W( <br />Facility Address. <br />Well Address: <br />WP# cyC <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 />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 />Well#: <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />,-7 <br />GROUTING or DESTRUCTION Total Deph: J <br />Depth to Water: 10 r <br />Grout Material: `e—t <br />Gallons of Grout Used: ja <br />❑Well Installation ❑Well Destruction <br />El Boring Installation�Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �fremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bas <br />Water <br />allons <br />Cement 94 lb <br />Ba s <br />Thickest Thinnest <br />ttBags <br />Thickest Thinnest <br />9Bags <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 />4q <br />8 <br />40 <br />80 <br />8 <br />CONSTRUCTION <br />Total Depth: n A & it <br />Drilling Rig Type: ' �/(c( <br />Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION ❑ Stove Pipe []Christie Box <br />casing <br />height <br />ABOVE -GROUND C4 -S M -BOX <br />COMfPLET10N comPLETION <br />Ground sLxtacs +— <br />grout <br />ft. <br />ft. <br />ft. <br />o <br />_ o <br />slotted = c <br />sacdon <br />9i+ p- <br />--k <br />MATERIALS/DEVELOPM ENT <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 />4ugq<<ft) �Zo ( f I C� 10/16/2017 <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />