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Date: <br />Facility A ddress: <br />Well Address: <br />Insinctor: 4 tef,A <br />14 1-P V)(211,11'M <br />wp# 004-ker <br />Soil Boring#: <br />Drilling Comp. @etei< <br />Driller Onsite7 <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Ve'rified: El Yes 0No <br />To: <br />To: <br />To: <br />To: <br />COMPLETION 0 Stove Pipe <br />casing <br />height <br />0 Christie Box <br />cd-sisri-pox <br />COMPLETI9N <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />From: <br />From: <br />From: <br />From: <br />SAICJOAQUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Consultant: <br />Geologist: <br />Public Water System Onsite: LI Yes <br />Domestic Well Onsite: 0 Yes Nt No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: LII Yes EINo <br />SPOILS <br />Contamination Noted: 0 Yes 0 No <br />If yes, spoils storage Location: <br />Covered: 0 Yes II1No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />El Well Installation OWell Destruction <br />)(111Boring Installation Boring Destruction <br />METHOD USED <br />liIPressure Grout Li Over Drill <br />lyi Gravity Nremie 00ther: <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest 4 Bags Thickest Thinnest 4 Bags <br />2.5 s 1 5 10 1 <br />s 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 />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 T 209 468-3420! F 209 464-0138 I www.sicehd.com