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ON <br />°RCII °2 SKJOAHIN <br />a rygC% —COUNTY— <br />A.c,FoaN¢. Greatness grows here <br />Environmental Health Department <br />❑ Yes El No <br />To: <br />To: <br />To: <br />To: <br />Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />IAMPI IIVr,' <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody: <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />If yes, material: /��(j <br />GROUTING or DESTRUCTION Total Depth: 20 �T l/ 1. X 3) <br />Depth to Water: <br />Y10 lok,- <br />Grout Material: <br />Gallons of Grout Used: MATERIALS/DEVELOPMENT <br />Casing Type: <br />❑Well Installation\` []WellWell Destruction <br />❑Boring Installation`]�oring Destruction <br />KAPTNnn t 14ZPn <br />❑Pressure Grout ❑Over Drill <br />Gravity ❑Tremie ❑Other: <br />Water <br />gallons <br />Monitoring Well/Soil Boring Inspection Report <br />Water <br />gallons <br />Cem 941b <br />Thickest Thinnest <br />z1 �ZI <br />4, <br />tlBags <br />Date: Ins ector: <br />Oc%/n' <br />CONSTRUCTION <br />Facility Address: C, 10 <br />- 00 <br />2 <br />Well Address: <br />2 <br />Total Depth: <br />WP# .S <br />Well#: <br />Drilling Rig Type: <br />Soil Boring#: �1 — <br />4 <br />Min 2" Annular EHD Seal Verified: <br />Drilling Company: �,�Yr�a-i!�yl <br />12.5 25 <br />5 <br />Driller Onsite: <br />Screen Length From: <br />Consultant: ?iY <br />30 60 <br />Filter Pack From: <br />Geologist: p h <br />7 <br />Bentonite From: <br />7 <br />20 40 <br />Grout From: <br />❑ Yes El No <br />To: <br />To: <br />To: <br />To: <br />Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />IAMPI IIVr,' <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody: <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />If yes, material: /��(j <br />GROUTING or DESTRUCTION Total Depth: 20 �T l/ 1. X 3) <br />Depth to Water: <br />Y10 lok,- <br />Grout Material: <br />Gallons of Grout Used: MATERIALS/DEVELOPMENT <br />Casing Type: <br />❑Well Installation\` []WellWell Destruction <br />❑Boring Installation`]�oring Destruction <br />KAPTNnn t 14ZPn <br />❑Pressure Grout ❑Over Drill <br />Gravity ❑Tremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cem 941b <br />Thickest Thinnest <br />ttBags <br />Thickest Thinnest <br />tlBags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 10 <br />2 <br />10 20 <br />2 <br />7.5 15 <br />3 <br />15 30 <br />3 <br />10 20 <br />4 <br />20 40 <br />4 <br />12.5 25 <br />5 <br />25 5 <br />15 30 <br />6 <br />30 60 <br />6 <br />17.5 35 <br />7 <br />35 <br />7 <br />20 40 <br />8 <br />40 80 <br />8 <br />Blank 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 />Screen Feet <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.411 2.47 <br />Bentonite per 94 Ib 2.821 4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.socehd.com <br />