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10/16/2 017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sicehd.com <br />SAN,d0AQUIN <br />4. • COUNTY . <br />Greotne.ss grows he. <br />Environmen Health Department <br />El Yes ONo Verified Chain of Custody: <br />SPOILS <br />El Gravity <br />Gallons of Grout Used: 0 <br />ElWell Installation P<II Destruction <br />EBoring Installation OBoring Destruction <br />METHOD USED <br />LIPressure Grout 12<er Drill <br />Vremie DOther: <br />Monitoring Well/Soil Boring Inspection Report <br />Date: I V Inspector; <br />Facility ddres 77 jj <br />Well Address: <br />WP# /JP 00 ; V.) 7,7 wellit: 0//, <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: f- <br />amys-ci- <br />c v 6 . <br />.P/14-e-0-14 <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: El Yes IDNo <br />To: <br />To: <br />To: <br />To: <br />From: <br />From: <br />From: <br />From: <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 />Contamination Noted: CI Yes 111 No <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: //— • <br />Grout Material: <br />Water <br />gallons <br />Cement 47Ib <br />Bags <br />Water <br />gallons <br />Cement 94 lb <br />Bags <br />Thfckest Thinnest 1/ Bags Thickest Thinnest 4 Bags <br />25 5 1 5 10 1 <br />5 10 2 10 20 2 <br />7,5 15 3 15 30 a <br />la 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 />COMPLETION CI Stove Pipe El Christie Box <br />casing <br />he ight <br />CHRISTY-EOX <br />COMP LET19N <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 />CONSTRUCTION <br />Yes EINo <br />El Yes IllNo <br />El Yes ON°