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P3, <br />SAN,,IOAQUIN <br />—COUNTY— <br />_ Grectness aror>5 here. <br />Environmental Health Department <br />Z <br />Monitoring Well/Soil Boring Inspection Report <br />t V1C <br />a e. nspec or. <br />Premise Address: `5 . (� <br />WP#: 00 <br />Well#: <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: ��� :^ <br />Consultant: <br />Geologist: ����� 0..0 <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 />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />El Yes ❑No <br />11` Yes L10' <br />❑ Yes ❑No <br />El Yes l 0 <br />❑ Yes ❑No <br />If yes, material: **- <br />GROUTING or DESTRUCTION Total Depth: —31C) <br />ZDepth to Water: ' b s <br />Grout Material: tJ� <br />Gallons of Grout Used: _ -5 <br />❑Well Installation ❑Well Destruction <br />❑Boring Installatio,l oring Destruction <br />METHOD USED ✓ <br />❑Pressure Grout ❑Over Drill <br />ElGravity Tremie ❑Other: <br />Water <br />allons <br />Screen Length <br />Cement 47 lb <br />Bas <br />Water <br />lions <br />From: <br />Cement 941b <br />Bais <br />Thickest Thinnest <br />t Bags <br />Thickest Thinnest <br />Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <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 />8o <br />8 <br />ONSTRUCTION <br />Total Depth: <br />Drilling Rig Type <br />Min 2" Annular Seal Verified: <br />Screen Length <br />From: <br />Filter Pack <br />From: <br />Bentonite <br />From: <br />Grout <br />From: <br />COMPLETION ❑ Stove Pipe <br />❑ Yes ❑ No <br />To: <br />To: <br />To. <br />To: <br />❑Christie Box <br />ft. <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/Gement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />