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� = ` SAMAQUIN <br />—COUNTY— <br />\`O�te1 Greotness grows mere <br />Environmental Health Department <br />Domestic Well Onsite: <br />If yes, location and distance: <br />Mon'i'toring Well/Soil Boring Inspection Report <br />Date: �'ZmA's <br />Inspector: W <br />CONSTRUCTION <br />Facility Address: <br />Z 2Z 1 <br />8Bags <br />Well Address: <br />Method: <br />Total Depth: <br />WP# � Q Ll- <br />SS Well#: <br />Drilling Rig Type: <br />Soil Boring#: <br />Verified Chain of Custody: <br />Min 2" Annular EHD Seal Verified: <br />Drilling Company: <br />AA 4 IQ_ <br />10 <br />Driller Onsite: <br />Contamination Noted: <br />Screen Length From: <br />Consultant: <br />If yes, spoils storage Location: <br />Filter Pack From: <br />Geologist: <br />Covered: <br />Bentonite From: <br />El No <br />4 <br />Grout From: <br />Public Water System Onsite: ❑ Yes ❑No <br />COMPLETION ❑ Stove Pipe <br />Domestic Well Onsite: <br />If yes, location and distance: <br />❑ Yes <br />[]No <br />SAMPLING <br />Cement 941b <br />Bags <br />Holding Temperature: <br />8Bags <br />Thickest Thinnest <br />Method: <br />2.5 <br />5 <br />Screening Method: <br />5 <br />10 <br />Verified Chain of Custody: <br />❑ Yes <br />❑No <br />SPOILS <br />10 <br />20 <br />Contamination Noted: <br />❑ Yes <br />❑No <br />If yes, spoils storage Location: <br />15 <br />30 <br />Covered: <br />❑ Yes <br />El No <br />casing <br />height <br />, —WWT tj <br />ABOVE -GROUND <br />cmRwryC0 PLETION 1oN a <br />carvune sts+aoe <br />or <br />tt. <br />tt. <br />je­ <br />� Cd�cfor SUkb� <br />slotted'! <br />sac:on :* _ <br />= 9-91 Pack <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />If yes, material: = z IaZC� <br />GROUTING or DESTRUCTION /Total Depth: <br />Depth to Water: c _/'tj CD I- <br />Grout Material:y 6y <br />Gallons of Grout Used: <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />❑Well Installation ❑Well Destruction �bs>° Blank Feet <br />re <br />Slot Size: <br />❑Boring Installation Boring Destruction Cl ���+L� <br />7eS�, �o I,p � Bags of Cement: <br />METHOD USED l Bags Sand/Gravel: <br />❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: _ <br />Filter Pack Type/Size: <br />❑ Gravity " Tremie ❑Other: Type of Method: <br />Water <br />allons <br />Cement 471b <br />Bags <br />Water <br />stallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />8Bags <br />Thickest Thinnest <br />aBags <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 />1 30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />1 35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />1 40 <br />80 <br />8 <br />z e, <br />Screen Feet <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonfte per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />Ncte' Or ��,n re, -,o- 1k W P o o 3%310 <br />coil{ d 'Qt 'r o, dell, vjh-.0 • -�ejl <br />aAa -,s �s rayed u. au wQ 00 3 9455 aS <br />-�M� C%o1P_ ;V1Xr�c..► ct� c� V✓ell 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 />