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SAN JOAQUIN <br />COUNTY— <br />�cIP/ Greatness grows here. <br />Moni <br />Date: � - Inspector: <br />Facility Address: Z 5q 1 <br />Well Address: <br />WP# % <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />Public Water System Onsite <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature <br />Method: <br />Well#: <br />Environmental Health Department <br />ring Well/Soil Boring Inspection Report <br />rr CONSTRUCTION �A <br />6uit <br />�o f Depth:(J <br />Water <br />pallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />Drilling Rig Type:( <br />Thickest Thinnest <br />Min 2" Annular EHD Seal Verified: <br />❑ Yes ❑No <br />- Screen Length From: <br />To: <br />Filter Pack From: <br />To: <br />Bentonite From: <br />To: <br />Grout From: <br />To: <br />❑ Yes 11 No COMPLETION ❑ Stove Pipe El Christie Box <br />❑ Yes ❑ No <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑No <br />conn c <br />Contamination Noted: ❑ Yes El No <br />If yes, spoils storage Location: <br />Covered: <br />If yes material: <br />❑ Yes ❑ No <br />I <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: I Z, 10 S r, <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation [goring Destruction <br />nnrTunn i icrn <br />El Pressure Grout Over Drill <br />❑ Gravity remie El Other: <br />Water <br />allons <br />Cement 47 lb <br />Bags <br />Water <br />pallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />4Bags <br />Thickest Thinnest <br />JI Bags <br />2.5 <br />5 <br />1 <br />5 10 <br />1 <br />5 <br />10 <br />2 <br />10 20 <br />7.5 <br />15 <br />3 <br />15 30 <br />3 <br />10 <br />20 <br />20 40 <br />4 <br />12.5 <br />25 <br />5 <br />25 50 <br />5 <br />15 <br />30 <br />30 60 <br />6 <br />17.5 <br />35 <br />7 <br />35 70 <br />- <br />20 <br />40 <br />8 <br />40 80 <br />8 <br />casing <br />ril <br />height <br />ABOVE -GROUND ctR:Srr-Sox <br />CO f.'>P LE MN COMPLEnCN <br />Ground Surfacs <br />grout <br />tt. <br />n. <br />tt. <br />— o <br />slotted <br />ax:en <br />crawl Pads <br />tt. = tt. <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 1.41 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.socehd.com <br />