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SANAAQUIN <br />COU NT Y— <br />Greo tness grows here. <br />Environmer 1 Health Department <br />Public Water System Onsite: El Yes 0No <br />LI Gravity <br />IIIPressure Grout 00ver Drill <br />1110ther: <br />Covered: <br />If yes, material: <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 1 Inspector: ti-(7t <br />Facility ddre s: 5-3 j ,S: 1.A-21— S4' <br />Well Address: <br />WP# i,/ Pao 5 7 ...r..S--- w ett#: <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: <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 />24s ON° <br />GROUTING or DESTRUCeOel /Total Depth: / / <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: ofr 1-3 0 <br />El Well Installation El Well Destruction <br />111Boring Installation UficirTng Destruction <br />METHOD USED <br />Water <br />gallons <br />Cement 47Ib <br />Bags <br />Water <br />gallons <br />Cement 94113 <br />Bags <br />Thickest Thinnest II 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: 0 Yes 0No <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION III Stove Pipe <br />casing <br />height <br />III Christie Box <br />cHnI.F3TY-pox • <br />comPLEn°N <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 I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I. www.sicehd.com <br />El Yes EINo <br />0 Yes IDNo