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SAN-IOAQUIN <br />, Environmental Health Department <br />. i• .,,, —COUNT Y— <br />�F <br />Greatness groves here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: �rInspector: OILCONSTRUCTION <br />Facility Address: _' _Cyl t <br />Well Address: Total Depth: O ` 0 <br />WP# Well#: Drilling Rig Type: i <br />s k d S�Lc?00 j 4,q <br />Soil Boring#: Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br />Drilling Company: f <br />Driller Onsite: 1-z—, CL- d L Screen Length From: To: <br />Consultant: C,oyI.eLC Filter Pack From: To: <br />Geologist: e -t ref- i S Bentonite From: To: <br />Grout From: 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 />SAMPLING <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: <br />GROUTING or DESTRUCTION Total Depth: �v <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation `` �_❑]Well Destruction <br />❑Boring Installation}1 Lring Destruction <br />MF:TNnn i lrPn <br />❑Pressure Grout ❑Over Drill <br />Gravity ❑Tremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bas <br />Water <br />gallill ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br /># Bags <br />Thickest Thinnest <br />4 Bags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 10 <br />2 <br />10 20 <br />2 <br />7.5 <br />3 <br />15 30 <br />3 <br />10 o <br />20 40 <br />4 <br />12.5 25 <br />5 <br />25 50 <br />5 <br />15 30 <br />6 <br />30 60 <br />6 <br />17.5 35 <br />7 <br />35 70 <br />7 <br />20 40 <br />8 <br />40 80 <br />8 <br />WTcasing <br />height <br />ABOVE -GROUND GIiASSTY SOX <br />COA �LET10N comPLEncN <br />Ground Surfak* <br />grout <br />ft. <br />ft. <br />ft. <br />— w <br />-- o <br />slonad _ <br />ssc�on <br />tL <br />MATERIALS/DEVELOPMENT <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 Feet <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94.1b 2.82 4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sucehd.com <br />