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SAN-JOAQUIN Environmental Health Department <br />—COUNTY— <br />Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: Inspector: COQ CONSTRUCTION <br />Facility Address: �-A <br />Well Address: Total Depth: L7 D <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#: Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br />Drilling Company: <br />Driller Onsite: Screen Length From: To: <br />Consultant: Filter Pack From: To: <br />Geologist: 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 />cnnnoi inir <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 />If yes, material: <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />-) <br />GROUTING or DESTRUCTION Total Depth: -5L/ <br />Depth to Water: -7- 0 <br />Grout Material: ( -"p,1,,,� , <br />Gallons of Grout Used: ?L <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Woring Destruction <br />METHOD USED <br />[]Pressure Grout ❑Over Drill <br />❑ Gravity 41,Tremie ❑Other: _ <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />wallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />9 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 />-5 50 <br />5 <br />15 30 <br />— <br />30 60 <br />6 <br />17.5 35 <br />7 <br />35 70 <br />7 <br />20 40 <br />40 80 <br />8 <br />casing <br />4MT height <br />ABOVE-GRCLItan c HISS Y -Box <br />COWLS ION COMPLETION <br />Ground surras T <br />grout <br />n. <br />fi. <br />ft. <br />— o <br />s[ottwd <br />IF <br />ynvsi yacis <br />I Ftt. <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 />Benton ite(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, Califomia 95205 1 7 209 468-34201 F 209 464-0138 1 www.sicehd.com <br />