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SANQ'JOAQUIN I Environmental Health Department —COUNTY— J+Y `C�CIFtiCi�v'I Greatness groves here. Domestic Well Onsite: If yes, location and distance: SAMPLING Holding Temperature: Method: Screening Method:_ Verified Chain of Custody SPOILS Contamination Noted: If yes, spoils storage Location: ❑ Yes ONO ❑ Yes ❑ No ❑ Yes ONO casing height ii1H—T l��i� �f ABOVE-GFIOUND coNFLEmN r :• COMPLETiON Gayindsurfacs ft - slotted ILA-aenrl �, 4�=Z • -• ■ Yes ■ No If yes, material: Monitoring Well/Soil Boring Inspection Report %/ 3/ 1( tZ = :. GROUTING or DESTRUCTIONTotal Depth: 2� Thickest Thinnest 2.5 5 10 Date: `I Inspector: ✓�L� (K/ CONSTRUCTION Facility Address: ' ' w spry. 7.5 Well Address: (A'►• e WP# 0c)y e6 Si,Oil Total Depth: �G`(U � Casing Type: ❑Well Installation ❑Well Destruction Well#: § ring Installation ❑Boring Destruction Drilling Rig Type: Soil Boring#: Z2 -C>U 2 2 - METHOD USED Bags Sand/Gravel: Drilling Company: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Min 2" Annular EHD Seal Verified: 11 Yes ONO Driller Onsite: Type of Method: 17.5 Screen Length From: To: Consultant: 35 70 7 Filter Pack From: To: Geologist: 6(w C" 4y ^ (/� 40 80 Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes ONO COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: If yes, location and distance: SAMPLING Holding Temperature: Method: Screening Method:_ Verified Chain of Custody SPOILS Contamination Noted: If yes, spoils storage Location: ❑ Yes ONO ❑ Yes ❑ No ❑ Yes ONO casing height ii1H—T l��i� �f ABOVE-GFIOUND coNFLEmN r :• COMPLETiON Gayindsurfacs ft - slotted ILA-aenrl �, 4�=Z • -• ■ Yes ■ No If yes, material: 1 Cement 471b Bas = :. GROUTING or DESTRUCTIONTotal Depth: 2� Thickest Thinnest 2.5 5 10 #Bags --1- - - 2 Depth to Water:—^- ,35 n - 1 _ 10 20 2 7.5 Grout Material: c, -I C ert 3 L, MATERIALS/DEVELOPMENT Gallons of Grout Used: ^-ID 91,9, 16^�� o 3 Casing Type: ❑Well Installation ❑Well Destruction Blank Feet § ring Installation ❑Boring Destruction Slot Size: 12.5 Bags of Cement: METHOD USED Bags Sand/Gravel: 5 Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: ❑ Gravity ) 1 remie ❑Other: Type of Method: Water 1 Cement 471b Bas Water gallons Cement 941b Bags Thickest Thinnest 2.5 5 10 #Bags --1- - - 2 Thickest Thinnest #Bags 5 A 1 _ 10 20 2 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 B 40 80 8 Screen Feet Bentonite/Gement Mix 3% Mix --'-1 4 11 5% Mix 2.47 Ueritani e per 4-i Ib Bentonite per 94 Ib 2.82 4.7 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com