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SAN JOAQUIN <br />---COUNTY <br />Greatness grows f7ere. <br />Date: 2� <br />Facility Address:[ <br />Well Address: <br />Soil Boring#: � (a 1 <br />Drilling Company: _ <br />Driller Onsite: <br />Consultant <br />Geologist: <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Inspector: <br />Well#: <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 ❑No <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑Yes ❑No <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />COMPLETION <br />From: To: <br />From: To: <br />From: <br />From: <br />❑ Stove Pipe <br />To: <br />To: <br />❑Christie Box <br />SPOILS <br />Contamination Noted: ❑Yes ❑ No <br />If yes, spoils storage Location: <br />Covered: ❑Yes ❑Nod ` `,R �� <br />If yes, material: off,\ C.� <br />GROUTING or -DESTRUCTION Total -Depth: j�� �- j� — -- ---- <br />Depth to Water: 2 � <br />Grout Material• �IQ;E}�,� ��.�� <br />MATERIALS/DEVELOPMENT <br />Gallons of Grout Used: � I,��f�,l . <br />❑Well Installati <br />❑Boring Install <br />METHOD USED <br />❑Pressure Grog <br />❑ Gravity <br />�Tremie ❑Other: <br />Water <br />allons <br />Cement 47ib <br />Bas <br />S°l° Mix <br />Water <br />allons <br />Cement 941b <br />Ba s <br />Thickest <br />Thinnest <br />� Bags <br />4.7 <br />Thickest <br />Thinnest <br />� Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />s <br />10 <br />2 <br />10 <br />zo <br />z <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />SO <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 <br />8 <br />Casing Type: <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 <br />Feet <br />BentonitefCement Mix <br />3°!° Mix <br />S°l° Mix <br />Bentonite per 47 Ib <br />1.41 <br />2.47 <br />Bentonite per 94 Ib <br />2.82 <br />4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sicehd.com <br />