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SANJOAQUIN <br />COU NTY— <br />Gr_c.-b arca s here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: l�! f Inspector: <br />CONSTRUCTION <br />Premise Address: _ <br />WP#: <br />Total Depth: <br />Well#: <br />Drilling Rig Type: <br />Soil Boring#: <br />2.5 <br />Drilling Company: <br />Min 2" Annular Seal Verified: <br />Driller Onsite: <br />Screen Length From: <br />Consultant: <br />Filter Pack From: <br />Geologist: <br />Bentonite From: <br />10 <br />Grout From: <br />Public Water System Onsite: ❑ Yes ❑No <br />COMPLETION ❑ Stove Pipe <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />CARAPI M <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody <br />conn c <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes El No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION Totpl Depth: <br />Depth to Water: <br />Grout Material: 1 <br />Gallons of Grout Used: <br />[--]Well Installation ❑Well Destruction <br />❑Boring Instal lation*oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity Aremie ❑Other: <br />Water <br />aiions <br />Cement 47 lb <br />Bas <br />Mater <br />vallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />it Bags <br />Thickest Thinnest <br />Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17,5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />40 <br />40 <br />80 <br />8 <br />❑ Yes ❑ No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />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 j 1.411 2.47 <br />Bentonite per 94 Ib 1 2.821 4.7 <br />�� Hazelto enue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />