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SMJOAQUIN <br />------COUNTY <br />Environmental <br />-----COUNTY <br />Environmental Health Department <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: ❑ Yes 11 No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: l <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation>613oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity P"remie ❑Other: <br />Monitoring Well/Soil Boring Inspection Report <br />Cement 471b <br />Bas <br />Water <br />gallons <br />C/ <br />Date: b Inspector: <br />CONSTRUCTION <br />Facility Address: <br />' <br />Well Address: <br />WP# 0 ®` <br />r" P4V L� Total Depth: <br />Well#: Drilling Rig Type: <br />Soil Boring#: <br />5 <br />Drilling Company: <br />Min 2" Annular EHD Seal Verified: 11Yes ❑No <br />!– <br />Driller Onsite: 43 <br />d . c L Screen Length From: To: <br />Consultant: %,.(-,fel <br />Filter Pack From: To: <br />;i ri C' <br />Geologist: � �� <br />�,� c Bentonite From: To: <br />7.5 <br />Grout From: To: <br />Public Water System Onsite: <br />❑ 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: ❑ Yes 11 No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: l <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation>613oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity P"remie ❑Other: <br />—r— casing <br />T height <br />ABOVE -GROUND GNRZ Y-BoX <br />CONFLETION ccMPLEncN <br />Ground surtxo <br />grout <br />n. <br />n. <br />n. <br />O <br />— o <br />slotted <br />Bacton '— B <br />7XV91 Pack <br />n. = n. <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 1.411 2.47 <br />Bentonite per 94 Ib 2.821 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.socehd.com <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />st Thinnest <br />RBa <br />Thickest Thinnest <br />ttBags <br />5 <br />1 <br />5 10 <br />1 <br />5 <br />10 <br />2 <br />10 20 <br />2 <br />7.5 <br />15 <br />3 <br />15 30 <br />3 <br />10 <br />20 <br />4 <br />20 40 <br />4 <br />12.5 <br />25 <br />5 <br />25 50 <br />5 <br />15 <br />30 <br />6 <br />30 60 <br />6 <br />17.5 <br />35 1 <br />7 <br />35 1 70 <br />7 <br />20 <br />40 1 <br />8 <br />40 1 80 <br />8 <br />—r— casing <br />T height <br />ABOVE -GROUND GNRZ Y-BoX <br />CONFLETION ccMPLEncN <br />Ground surtxo <br />grout <br />n. <br />n. <br />n. <br />O <br />— o <br />slotted <br />Bacton '— B <br />7XV91 Pack <br />n. = n. <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 1.411 2.47 <br />Bentonite per 94 Ib 2.821 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.socehd.com <br />