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SAN. JOAQUIN <br />COUNTY <br />Greotness grows iter.!.. <br />Facility Address:_ <br />Well Address: <br />WP# c <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist, <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 />Environmental Health Department <br />Monitoring Well/ oil Boring Inspection Report <br />Ar: CONSTRUCTION <br />� <br />Total Depth: r <br />Well#: "r _ <br />I'4b <br />� <br />Verified Chain of Custody: ❑Yes ❑ No <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: <br />Screen Length From:!~ <br />Filter Pack From: <br />Bentonite <br />Grout <br />COMPLETION <br />From: <br />From: <br />❑ Stove Pipe <br />❑ Y+00 <br />es ❑ N o <br />To: <br />To: <br />To: <br />To: ' L0C <br />❑Christie Box <br />Apo <br />1- • <br />`V Ins <br />SPOILS ft. - 4101141110100 <br />I <br />Contamination Noted: ❑ Yes ❑ No a" _ <br />If yes, spoils storage Location: &totter <br />&scion "— <br />Covered: ❑ Yes ❑ No <br />gnvat pact <br />If yes, material: <br />GROUTING or DESTRUCTION Total D <br />Depth to Water: <br />Grout Material: <br />5) <br />Gallons of Grout Used: MATERIALS/DEVELOPMENT <br />'ev I _. 16 sing Type: <br />)< ell Installation ❑Well Destruction ��r j Blank Feet Screen Feet <br />❑Boring Installation El Boring Destruction i l Slot Size: <br />\j Bags of Cement: <br />METHOD USED / Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />❑ Pressure Grout ❑Over Drill Mk��se <br />+� ' Filter Pack Type/Size: <br />Gravity envie ❑Other: Type of Method, <br />` �0 �� <br />Water Cement 471b Water Crment 941b <br />allons Bas allons Bags <br />Thickest Thinnest #Bags Thickest Thinnest Bags Bentonite/Cement Mix 3% Mix 5% MIX <br />2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 <br />5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 <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 60 6 <br />17.5 35 7 35 70 7 <br />20 40 8 40 80 8 <br />10/16/2017 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sicehd.com <br />