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SAN JOAQUIN <br />--COUNTY--- <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 1&411��O( -1 Inspector: VJI' �/y �) CONSTRUCTION <br />FacilityAddress:�500 A«yT MLA& <br />Well Address: U Total Depth: <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />Min 2" Annular EHD Seal <br />Screen Length From:_ <br />Filter Pack From: <br />Bentonite F <br />Grout 14 <br />Public Water System Onsite: <br />❑ Yes <br />4N <br />COMPLETION <br />Domestic Well Onsite: <br />❑ Yes <br />0 <br />.I\\ <br />Thickest Thinnest <br />If yes, location and distance: <br />2.5 <br />5 <br />1 <br />SAMPLING <br />1 <br />5 <br />Aao ao <br />Holding Temperature: <br />10 20 <br />2 <br />LE7>' <br />Method: <br />3 <br />15 30 <br />3 <br />Screening Method: <br />20 <br />4 <br />20 40 <br />Verified Chain of Custody: <br />❑ Yes <br />❑No <br />5 <br />25 50 <br />5 <br />15 <br />tt. <br />SPOILS <br />30 60 <br />6 <br />17.5 <br />Contamination Noted: <br />❑ Yes <br />[]No <br />7 <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />ol <br />Depth to Water: WIL <br />Grout Material <br />Stove Pipe <br />casing <br />hei ht <br />❑ Yes El No <br />To: <br />To: <br />To: <br />To: <br />[]Christie Box <br />slonad <br />sKJon <br />Gallons of Grout Used: S MATERIALS/DEVELOPMENT Casin T as <br />❑Well Installation ❑Well Destruction <br />[]Boring Installation )(Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ❑Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />izallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />pBags <br />Thickest Thinnest <br />#Bags <br />2.5 <br />5 <br />1 <br />5 10 <br />1 <br />5 <br />10 <br />2 <br />10 20 <br />2 <br />7.5 <br />15 <br />3 <br />15 30 <br />3 <br />10 <br />20 <br />4 <br />20 40 <br />4 <br />12.5 <br />25 <br />5 <br />25 50 <br />5 <br />15 <br />30 <br />6 <br />30 60 <br />6 <br />17.5 <br />35 <br />7 <br />35 70 <br />7 <br />20 <br />40 <br />8 <br />40 80 <br />8 <br />n. <br />g Yp <br />Blank Feet Screen Feet <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Grave <br />Type/Brand of enton e: <br />Filter Pack Ty e/Size: _ <br />Type of M od: <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 />�z Z/- <br />wwyl <br />1868 E. Hazelton Avenue Stockton, California 95205 T 209 46A- �42010 46 0138 www.sicehd.cc <br />10/16/2017 <br />G <br />