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SANS=IOAQUIN <br />♦ ,' i- ...rte °e, <br />~ Environmental Health Department <br />—COUNTY <br />dire tress gro.is here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: ZS Inspector: <br />Facility Address: <br />Well Address: <br />WP# Well#: <br />Soil Boring#: <br />Drilling Company:'%—� <br />Driller Onsite: AMt <br />Consultant: AM�C� <br />Geologist: T, LL <br />Public Water System Onsite: \] Yes El No <br />Domestic Well Onsite: ❑ Yes El No <br />If yes, location and distance: �y + <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑No <br />SPOILS /A <br />Contamination N ed: <br />If V- <br />if <br />esso' storage Location: <br />Cove <br />rial: <br />❑ Yes ONO <br />❑ Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth: (OC <br />Depth to Water: iC] <br />Grout Material: <br />Gallons of Grout Used: >\J <br />❑Well Installation ❑Well Destruction <br />El Boring Installation qBoring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity WTremie ❑Other: <br />Water <br />gallons <br />From: <br />Cement 471b <br />Bas <br />Filter Pack <br />Water <br />allons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />kBags <br />Thickest Thinnest <br />t7 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. <br />35 <br />7 <br />35 <br />70 <br />7 <br />0 <br />40 <br />8 <br />40 <br />80 <br />8 <br />v <br />CONSTRUCTION <br />Total Depth: _ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal V41fied: ❑ Yes ❑No <br />Screen Length <br />From: <br />To: <br />Filter Pack <br />From: <br />To: <br />Bentonite <br />From: <br />To: <br />Grout <br />From: <br />To: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />4��v <br />T <br />ABOVE -GROUND GiiFiiSTY 80X <br />COMPLETION CCUPLETiON <br />crodrid stslacs t <br />grout <br />w <br />— o <br />slottai —' <br />" — gri;vw Pack <br />VE—NNEER>� <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 1.41 2.47 <br />Bentonite per 94 Ib 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.smcehd.com <br />