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SANAJAQ.UTN <br />Co (.1 NTY— <br />Greatness grows here. <br />Environmental Health Department <br />Yes EN° Domestic Well Onsite: <br />otal Depth: <br />Boring Destruction El Boring Installation <br />METHOD USED <br />ElPressure Grout EiOver Drill <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 4 Inspector: Bftt10 <br />Facility Address: W C 110 re)Q <br />Well Address: <br />wp# 00 3?:02—(0 Well#: <br />Soil Boring#: MWs, / enr-14: <br />Drilling Company: ANN D <br />, <br />(p) I N L. <br />Driller Onsite: FRAN K <br />Consultant: <br />Geologist: <br />Public Water System Onsite: Ill Yes IllNo <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: El Yes IllNo <br />SPOILS <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: El Yes El No <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION Stove Pipe El Christie Box <br />I <br />casing <br />height <br />CHRMY-BOX - <br />COMPLETION <br />11 <br />ABOVE-GROUND <br />COmmiznorci <br />If yes, spoils storage Location: BQKI\Y011 &IIDP <br />Covered: A Yes IllNo . <br />If yes, material: dIrtiCeinair bore n-oie conPrni <br />Contamination Noted: es ON° <br />GROUTING or D'ESTRUCTION <br />Depth to Water: <br />Grout Material: I <br />Gallons of Grout Used: <br />ElWell Installation El Well Destruction <br />El Gravity ,Treniç0 e <br />Water <br />gallons <br />Cement 47lij <br />Bags <br />... <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest 4 Bags Thickest Thinnest 4 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 />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 />r C &INAtt-Fr Alae <br />VIO (WOO' ICW) (36111M/7S afiPtai-010 , 19011:11 <br />Avenue I Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 I www.sicehd.com <br />10/16/2 0 1 7 <br />;Ta Da <br />1868 E. Hazelt