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Date: <br />Facility ddre <br />Well Address: <br />WP# <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />A-1 <br />SANdOAQUIN <br />OUNTY— <br />Greotness grows here. <br />Environmer Health Department <br />I. Well#: <br />0 Yes ON° <br />EIlYes GINo <br />Public Water System Onsite: <br />Domestic Well Onsite: <br />If yes, location and distance: <br />Monitoring Well/Soil Boring Inspection Report <br />Inspector: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular END Seal Verified: <br />Screen Length From: <br />Filter Pack From: <br />Bentonite From: <br />Grout From: <br />COMPLETION El Stove Pipe <br />casing <br />height <br />(A(ai od Surf aca <br />VE-G ROUND <br />COMPLETION C4-1PISTY-p0X * <br />COMPLETION <br />111 Yes 111No <br />To: <br />To: <br />To: <br />To: <br />0Christie Box <br />Kr 641 <br />1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0136 f, www.sicehd.com <br />rl Gravity <br />EPressure Grout 00v r Drill kttv., <br />O <br />METHOD USED <br />) <br />OWell Installation EIW Rstell.D ruction i r <br />Boring Installation oring Destruction <br />4)1(16 <br />6 <br />Gallons of Grout Used: • <br />/ GROUTING or DESTRUCTION Total Depth:a-Z1 /06 j b <br />Depth to Water: pig) r-(14 <br />Grout Material: pi <br />P • <br />Verified Chain of Custody: 0 Yes ON° <br />Sil IV ft. SPOILS ______ft <br />Covered: [:I Yes 0No <br />If yes, material: <br />-ft. <br />If yes, spoils storage Location: <br /> <br />ft. <br />I I grzvoi pack <br />Contamination Noted: 0 Yes EN° <br />-e: <br />Screening Method: <br />remie <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />sic turd <br />zacUon <br />grout <br />10/16/2017 <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest It Bags <br />5 <br />10 <br />15 <br />20 <br />25 <br />30 <br />35 <br />40 <br />10 <br />20 <br />30 <br />40 <br />50 <br />60 <br />70 <br />80 <br />0 Other: <br />1 <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />Feet Screen Blank Feet <br />Slot Size: <br />Bags of Cement: <br />Rentoniteieement Mix Mix <br />2.82 Bentonite per 94 lb <br />5% Mix <br />Bentonite per 47 lb 2.47 1.41 <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />4.7