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pCd tly r..- <br />�' SANIOAQUIN Environmental Health Department <br />COUNTY <br />• o �' Greatness groes here. <br />k:a/'O� <br />Monitoring Well/Soil Boring Inspection Report <br />Date: iInspector: CONSTRUCTION <br />Faci14 Address. <br />Well Address: po Total Depth: <br />WP# Well#:) Drilling Rig Type: <br />Soil Boring#.�(Min 2" Annular EHD Seal Verified <br />Drilling Company: Screen Length <br />Driller Onsite: 2A ct <br />Consultant: <br />Filter Pack <br />Geologist: — jc�fOlk_ Bentonite <br />Grout <br />Public Water System Onsite: ❑ Yes �No COMPLETION <br />Domestic Well Onsite• ❑ Yes �Nln <br />❑ Yes 11 No <br />From: To: <br />From <br />From <br />From <br />❑ Stove Pipe <br />casing <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Cus� o ❑ Yes ❑No <br />SPOILS I <br />Contamination No\d: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Cover El Yes ❑No <br />I es, material: <br />r / <br />GROUTING or DESTRUCTION Total Dep h:Z_0 <br />Depth to Water. t L .r' . <br />Grout Material <br />To: <br />To: <br />To: <br />❑Christie Box <br />—fit. <br />Gallons of Grout Used: 1J MATERIALS/DEVELOPMENT <br />Casing Type: <br />❑Well Installation []Well Destruction <br />❑Boring Installation Boring Destruction <br />METHOD USED <br />❑Pressure Grout []Over Drill <br />❑ Gravity UTremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 94lb <br />Ba s <br />Thickest Thinnest <br />#B <br />Thickest Thinnest <br />#Bags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />s 10 <br />2 <br />10 20 <br />2 <br />7.5 15 <br />3 <br />15 Be <br />3 <br />10 20 <br />4 <br />20 40 <br />4 <br />1Z.5 25 <br />5 <br />25 so <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 1 80 <br />8 <br />Blank Feet Screen 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 />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.sicehd.com <br />