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SANdOAQUIP <br />, COUNT Y— <br />Greatness grows here. <br />Environme l Health Department <br />0 Yes El No <br />R4'es ENo <br />Verified Chain of Custody: <br />SPOILS <br />Contamination Noted: <br />0 nitvv-- <br />GROUTING or DESTRUCTION Total Depth:--(91 <br />Depth to Water: <br />ElOther: <br />EWell Installation ElWell Destruction <br />Li Boring Installation oring Destruction <br />METHOD USED <br />IEI Pressure Grout IllOver Drill <br />Li Gravity dllremie <br />Monitoring Well/Soil Boring Inspection Report <br />-) Inspector:4i 14-414. <br />5(1 <br />'',/vf S.Vit-13 <br />Date: <br />Facility addre s: <br />Well Address: <br />WP# <br />Soil Boring <br />Drilling Compan : <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />Well#: <br />iA <br />Public Water System Onsite: 0 Yes ElNo <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />If yes, spoils storage Location: 01, Silt- <br />Grout Material: CtA,—.4.„._A-- <br />Gallons of Grout Used: U..) <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest # Bags Thickest Thinnest # Bags <br />2.5 5 1 5 10 1 <br />5 10 2 10 20 2 <br />7.5 15 3 15 30 3 <br />10 20 4 20 40 4 <br />12.5 25 5 25 50 5 <br />15 30 6 30 60 6 <br />17.5 35 7 35 70 7 <br />20 40 8 40 80 8 <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: CI Yes lilNo <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION 0 Stove Pipe 0Christie Box <br />casing <br />height <br />cHrzus-ricpox <br />COMPLET19N <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet Screen 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 />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 lb 1.41 2.47 <br />Bentonite per 94 lb 2.82 4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I, www.sicehd.com <br />0 Yes I=1No <br />Covered: <br />If yes, material: <br />L2K'es ONo