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Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: El Yes 0No <br />To: <br />To: <br />To: <br />To: <br />COMPLETION CI Stove Pipe EChristie Box <br />Grocind Surfacs <br />gravel pock <br />ft <br />ft <br />ft <br />ft. <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />casing <br />I height <br />ca-ousre-Box <br />COMPLETION <br />11 <br />ABOVE-GROUND <br />CO&PLETION <br />From: <br />From: <br />From: <br />From: <br />GROUTING or DESTRUCTION Toy Depth: / IV <br />Depth to Water: <br />SANAOAQUIN <br />COUNTY <br />Greatness grows here. <br />Date: 7nspector: <br />Facility dress: '7,49 S1 5 <br />Well Address: lop 4 t . c. w. <br />wP# 4/190 0 -3 i( 6'9 Well#: <br />Soil Boring#: C4271 - 7 &__ 11(/ i 20 i Drilling Company: i 4 CC 7 i <br />Driller Onsite: re•-• ---3Pet--3 <br />Consultant: -----.-FCCAV51140) <br />Geologist: Foliatv% 77^-eAdtal, <br />Public Public Water System Onsite: El Yes IIINo <br />Domestic Well Onsite: GI Yes 0No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: DI Yes 0No <br />SPOILS <br />Contamination Noted: El Yes ENo <br />If yes, spoils storage Location: <br />Covered: 0 Yes El No <br />If yes, material: <br />/44,* <br />Gallons of Grout Used: r <br />111 Well Installation 0Well Destruction <br />El Boring Installation Ili'ring Destruction <br />METHOD USED <br />0Pressure Grout 0Over Drill <br />D Gravity 1‹-ernie 00ther: <br />Water <br />gallons <br />Cement 47 lb <br />Bags <br />Water <br />gallons <br />Cement 94Ib <br />Bags <br />Thickest Thinnest # Bags Thickest Thinnest #Bags <br />2.5 s 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 9 40 80 8 <br />Environment, lealth Department <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 />0 <br />Grout Material: <br />Monitoring Well/Soil Boring Inspection Report <br />31-7 1868 E. Hazel / on Avenue Stockton,‘6alifomia 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com <br />10/16/2017