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SAN.JOAQUIN <br />—COUNTY— <br />Grentness grov.i Fi,rr. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: II A Inspector: <br />21�0a <br />Premise Address: C>j <br />W P#:VV <br />Well#: <br />Soil Boring#:�� <br />Drilling Company: Q C -4--V\-/ <br />Driller Onsite: <br />Consultant: _ <br />Geologist: <br />CONSTRUCTION <br />Total Depth: � <br />Drilling Rig Type: \A <br />i � <br />W <br />Cement 47 lb <br />sags - <br />Min 2" Annular Seal Verified: <br />Yes 11 No <br />Screen Length From: <br />To: <br />Filter Pack From: <br />To: <br />Bentonite From: <br />To: <br />Grout From: <br />To: <br />Public Water System Onsite: ❑ Yes ❑No I 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 />If yes, material: <br />❑ Yes ❑No <br />❑ Yes El No <br />❑ Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth: io l �' <br />Depth to Water: t c <br />Grout Material:^ <br />Gallons of Grout Used:V• <br />❑Well Installation ❑Well Destruction Yloryvl <br />D No <br />❑Boring Installation ❑Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />�'i <br />El Gravity 'lemie ❑Other: _ <br />Water <br />allons <br />Cement 47 lb <br />sags - <br />Water <br />eallons <br />Cement 941b <br />Bois <br />Thickest Thinnest <br />11 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 />9 <br />10 <br />20 <br />4 <br />20 <br />40 1 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 1 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />40 <br />00 <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 <br />Feet <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 />go HtvL t <br />1868 E. Hazelto venue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />01/1 <br />S�a <br />