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SKJOAQUIN Environmental Health Department lttf`:, —COUNTY- -. _ Gr_a: oroFs here, .rR-� gag Well/Soil Boring Inspection Report Date: Inspector: , �1 _ CONSTRUCTION Premise Address: �C� WP#: Total Depth: zgo Well#: Drilling Rig Type: Soil Boring#: Min 2"Annular Seal Verified: ❑ Yes ❑No Drilling Company: tS Driller Onsite: Screen Length From: To: Consultant: Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: yes ❑No 1 casing If yes, location and distance: height SAMPLING A,sovE-GROUND Holding Temperature: cowLETION CCMPLEnON Method: G=nd&KI"' Screening Method: ar«� Verified Chain of Custody: ❑ Yes ❑No s ft- SPOILS —r� — Contamination Noted: ❑ Yes ❑No If yes,spoils storage Location: stoned A = 3 Covered: ElYes ❑No aeon9-vw pack 'w If yes, material: 7' — .. GROUTING or DESTRUCTION Total Depth:--Luo ;W __ Depth to Water: tt• ft• Grout Material: 4n4 MATERIALS/DEVELOPMENT Gallons of Grout Used: / `•� "0Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet ❑ Slot Size: Boring Installation ❑Boring Destruction Bags Size: Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout Dover Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity ❑Tremie ❑Other: Type of Method: water Cement 471b Water Cement 941b gallons Bas - gallons Bags Thickest Thinnest #Bags Thickest Thinnest #Bags 2.5 s 1 5 10 1 Bentonite/Cement Mix 3% Mix 5% Mix 5 10 2 10 20 2 Bentonite per 47 Ib 1.41 2.47 7.5 15 3 15 30 3 — 10 20 4 20 40 a Bentonite per 94 Ib 2.82 4.7 12.5 25 5 25 50 S 1 30 30 50 17.. 7 75 35 7 35 70 7 20 40 8 40 80 8 1868 E. Hazelton Avenue 1 Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.c