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(S_'Z'°fC.,z SAN._JOAQUIN <br />—COUNTY— <br />Greatness grows here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />❑ Yes []No <br />To: <br />To: <br />To: <br />To: <br />Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <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 El No <br />SPOILS <br />Contamination Noted: ❑ Yes El No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />1 <br />iepitloiater:_ <br />dTotal Depth: i\'Iz " Z� ��L <br />\(� ���(� <br />Grout Material: No SG1Uv-- <br />G Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />�\ <br />❑Boring Installation 5913oring Destruction 11 <br />METHOD USED �� +1 bcjrll 3S*5) <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ❑Tremie ®Other: like W <br />Water <br />allons <br />Vane WMg A, <br />' <br />Water <br />gallons <br />Date: <br />Inspector: ) .V- ctyyloa' <br />CONSTRUCTION <br />Facility Address: -.'ILA <br />5 'W • 1 i -c L" -e <br />#Bags <br />Well Address: <br />1 <br />Total Depth: <br />WP#(offj <br />Well#: <br />Drilling Rig Type: <br />Soil Boring#: N <br />O ' D \ <br />20 <br />Drilling Company: <br />V 3 VlAking Zink. <br />Min 2" Annular EHD Seal Verified: <br />Driller Onsite: <br />30 <br />Screen Length From: <br />Consultant: <br />4 <br />Filter Pack From: <br />Geologist: <br />4 <br />Bentonite From: <br />5 <br />25 <br />Grout From: <br />❑ Yes []No <br />To: <br />To: <br />To: <br />To: <br />Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <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 El No <br />SPOILS <br />Contamination Noted: ❑ Yes El No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />1 <br />iepitloiater:_ <br />dTotal Depth: i\'Iz " Z� ��L <br />\(� ���(� <br />Grout Material: No SG1Uv-- <br />G Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />�\ <br />❑Boring Installation 5913oring Destruction 11 <br />METHOD USED �� +1 bcjrll 3S*5) <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ❑Tremie ®Other: like W <br />Water <br />allons <br />Cement 47lb <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 <br />10 <br />1 <br />5 10 <br />2 <br />10 <br />20 <br />2 <br />7.5 15 <br />3 <br />15 <br />30 <br />3 <br />10 20 <br />4 <br />20 <br />40 <br />4 <br />12.5 25 <br />5 <br />25 <br />50 <br />5 <br />15 30 <br />6 <br />30 <br />60 <br />6 <br />17.5 35 <br />7 <br />35 <br />70 <br />7 <br />20 40 <br />8 <br />40 <br />80 <br />8 <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 />ft. <br />Screen Feet <br />Bentonite/Gement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 lb 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.sicehd.com <br />