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Date: %Inspector; I I4-41/1"-- <br />Well Address: - <br />WP# 00 3 ci 0 2,-7 Went <br />Soil Boring#: <br />Drilling Company: 6401, - ,_cLoce_ <br />Driller Onsite: /LA <br />Consultant: <br />Geologist: *5:: LA-4W <br />Facility ddre : <br />A-66 <br />ABOVE-GROUND <br />COMPLErION <br />_ft. <br />casing <br />height <br />C11:191SrOX • <br />COMPLET19N <br />&mind Surface <br />giout <br />II <br />- <br />Environmen 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 />Yes LIN° <br />SPOILS <br />Contamination Noted: I=1 Yes <br />If yes, spoils storage Location: <br />Yes ONo <br />• Depth to Water: / <br />Grout Material: <br />Gallons of Grout Used: <br />ElWell Installation ell Destruction <br />ElBoring Installation OBoring Destruction <br />METHOD USED <br />EPressure Grout Rer Drill <br />12/c-avitylff<emie <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 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 GO 6 <br />17.5 35 7 25 70 7 <br />20 40 . 8 I 40 80 8 <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: 111 Yes LIN° <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION CIStove Pipe El Christie Box <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 i 2.82 4.7 <br />111Yes <br />El Yes <br />ElNo <br />LIN° <br /> <br />Covered: <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: 3,5.-f / <br />51" <br />30 171 • <br />10/16/2017 <br />1868 E. Hazelt n Avenue ockton, California 95205i T 209 468-3420 I F 209 464-0138 I www.sicehd.com