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Date: Inspector: <br />Facility <br />Well Address: <br />wp# ap 0 3 7St Well#: <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />COMPLETION El Stove Pipe 111Christie Box <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: CI Yes lEINo <br />To: <br />To: <br />To: <br />To: <br />casing <br />height <br />.1..drer.er <br />\ 011 <br />N....4k <br />CHRISTig3OX <br />compLE-ripN <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />From: <br />From: <br />From: <br />From: <br />SA LIOAQUIN <br />, —COUNTY <br />Grecitness grows here <br />Environmer Health Department <br />Monitoring Well/Soil Boring Inspection Report <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 />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />OWell Installation lcVell Destruction <br />EBoring Installation OBoring Destruction <br />METHOD USED <br />OPressure Grout Over Drill <br />LI Gravity 111Tremie El Other: <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thfckest Thinnest N Bags Thickest Thinnest 41 Bags <br />2,5 5 1 5 10 1 <br />5 10 2 10 20 2 <br />7,5 15 3 15 20 a <br />10 20 4 20 40 4 <br />12,5 25 5 "25 50 3 <br />15 30 6 30 a 6 <br />17,5 35 7 35 70 7 <br />20 40 8 40 80 8 <br />CONSTRUCTION <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 />Yes CI No <br />El Yes ON° <br />1=1 Yes ONo <br />El Yes 41.141: <br />1=1 Yes ON° <br />76 o <br />.,'( W (3.I./‘ YA #14 <br />1868 E. Hazelton venue S ockton, California 95205 I T 209 468-3420 I F 209 464-0138 1 www.sicehd.com 2 <br />i i 56 )j r 44s ' <br />10/16/2017