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SAN J OA Q U I N Environmental Health Department <br />—COUNTY <br />TS� Greatness ur;�ws ?rer�-. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: Inspector: CONSTRUCTION i <br />Facility Address: -Z— 't <br />pJ�edr Total Depth:i. <br />Wi ' v 1II#: Drilling Rig Type: <br />Soil Boring#: —M/14' <br />Drilling Company: Min 2" Annular EHD Seal Verified: El Yes ❑No <br />Driller Onsite: Screen Length From: To: <br />r � Filter Pack From: To: <br />Consultant: <br />Geologist: Bentonite From: To: <br />Grout From: To: <br />ZD <br />Public Water System Onsite: ❑ Yes ❑No <br />Domestic Well Onsite: ❑ Yes El No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: / <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes El No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring InstallationXoring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity �I.�Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />ltBags <br />Thickest Thinnest <br />uBags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 10 <br />2 <br />10 20 <br />2 <br />7.5 15 <br />3 <br />15 30 <br />3 <br />10 20 <br />4 <br />20 40 <br />4 <br />12.5 25 <br />25 50 <br />5 <br />1S 30 <br />6 <br />30 60 <br />6 <br />17.5 35 <br />35 70 <br />7 <br />20 40 <br />8 <br />40 80 <br />8 <br />COMPLETION ❑ Stove Pipe <br />❑Christie Box <br />casing {(„ <br />height U`'l $� <br />i <br />ABOVE -GROUND 80X <br />COWLEr30N ON <br />Ground Suiace <br />ft. <br />ft. <br />ft. <br />R '— o <br />3, Y <br />0 <br />stottad _- <br />Bacon <br />umvw Pack <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 /2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd. o <br />