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SAN JOAQUIN <br />Environmental Health Department <br />COUNTY <br />r Greatness grovv.s nerc. <br />J Monitoring Well/Soil Boring Inspection Report <br />Date: 1® / Z6/1, Inspector: V `� CONSTRUCTION <br />Facility Address: Z -5 17 1,k), <br />Well Address: Total Depth: <br />WP# c) 0 Well#: Drilling Rig Type: <br />Soil Boring#: I Min 2" Annular EHD Seal Verified: ❑Yes No <br />Drilling Company: <br />Driller Onsite: Screen Length From: To: <br />Consultant: ILII Filter Pack From: To: <br />Geologist: C Bentonite From: To: <br />Grout From: To: <br />Public Water System Onsite: ❑ Yes ❑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: <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes ❑ No <br />❑ Yes El No <br />❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: ' <br />Depth to Water: <br />Grout Material: L� <br />Gallons of Grout Used: v� <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Aoring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity A emie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br /># Bags <br />Thickest Thinnest <br />Bags <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 />5 <br />25 50 <br />5 <br />15 30 <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 />casing <br />height <br />ABOVE -GROUND CHRISTY-BOX <br />COMPLETION COMPLETION <br />Ground surra. <br />grout <br />ft. <br />is. <br />ft. <br />- — o <br />C <br />sbttQd <br />soon _ — <br />�� = Brawl pack <br />g, `= =IFtt. <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 />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 <br />' I �� <br />6/2017 <br />www.sicehd.com <br />