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SAN J OAQ U I N Environmental Health Department <br />- COUNTY <br />Monitoring Well/Soil Boring Inspection Report e <br />Date: "(5 Orvkzrl CONSTRUCTION r r <br />Facility Address: iZh <br />Z Loi Q_C. <br />Well Address: Total Depth: <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#: 9 <br />Drilling Company: Min 2" Annular EHD Seal Verified: El Yes ❑No <br />G I^' � CSi� C S �- <br />6.' Screen Length From: To: <br />Driller Onsite: <br />Consultant: rC�,_C0—^ Filter Pack From: To: <br />Geologist: % s -, Bentonite From: To: <br />0Grout From: To: <br />Public Water System Onsite: ❑ Yes ❑No 51-4 COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes ❑Nom <br />M4casing <br />If yes, location and distance: 0�1 ,�_ I height <br />NA � <br />SAMPLING ABOVE -GROUND <br />Holding Temperature: COWFLETION <br />Method: <br />Screening Method: <br />Verified Chain of Custody <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />G=na surface <br />grout <br />n. <br />tt. <br />n. <br />w <br />_ o <br />slottad <br />soon — B <br />GROUTING or DESTRUCTION Total Depth:_ I act tVf. =_ <br />Depth to Water: N / .S ont tt tt' <br />IF <br />Grout Material: a� ;jj jAeTERIALS/DEVELOPMENT <br />Gallons of Grout Used: to 6 <br />1P_M Casing Type: <br />❑Well Installation ❑Well Destruction IQ✓e- (Blank Feet Screen Feet <br />❑Boring Installation-gBoring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />XG ❑Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />Raill ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />#Bags <br />Thickest <br />innest <br />9Bags <br />2.5 5 <br />1 <br />10 <br />1 <br />5 10 <br />2 <br />10 <br />20 <br />2 <br />7.5 15 <br />3 <br />15 <br />30 <br />3 <br />10 20 <br />4 <br />20 <br />40 <br />4 <br />12.5 25 <br />5 <br />25 <br />50 <br />5 <br />15 30.Z <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />7 <br />35 <br />70 <br />7 <br />20 40 <br />8 <br />40 <br />80 <br />8 <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 />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 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.s4cehd.com <br />