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SAN�JOA UIN <br />_ Environmental Health Department <br />_ <br />COUNTY <br />err Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 12 l?) <br />Inspector: <br />Facility Address: <br />Water <br />wa111111 ons <br />Well Address: <br />Cement 941b <br />Baas <br />WP# 003 X10 <br />Well#: <br />Soil Boring#: <br />#Bags <br />Drilling Company: <br />U tl l <br />Driller Onsite: AB4i5'F:l— <br />5 <br />Consultant: <br />1 <br />Geologist: T-1 <br />0 <br />Public Water System Onsite <br />Domestic Well Onsite <br />If yes, location and distance: <br />UMPI ING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />❑ Yes ❑No <br />❑ Yes ❑No <br />CONSTRUCTION <br />Total Depth: _ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length From: <br />Filter Pack <br />Bentonite <br />Grout <br />COMPLETION <br />From <br />❑ Yes ❑No <br />To: <br />To: <br />From: To: <br />From: To: <br />❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />T T r <br />ABOVE -GROUND G iFiiSTY c30X <br />COiS LE71ON GOWLETION <br />Ground sur acs <br />procrt <br />Verified Chain of Custody: ❑ Yes ❑No Pi- 1 ✓ /tt. <br />SPOILS <br />Contamination Noted: ❑ Yes El No <br />If yes, spoils storage Location Q� ,ZSR stor d <br />Covered: El Yes El Nogrxvvi <br />If yes, material: ✓ 1 <br />GROUTING o ESTRUCTION Total Depth: p�� / '• =_ <br />Depth to Water: tN tt. n' <br />GroutMaterial: NkT QP&A[N <br />Gallons of Grout Used: L-32 MATERIALS/DEVELOPMENT <br />Casing Type: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Loring Destruction <br />METHOD USED ` <br />❑Pressure Grout ❑Over Drill <br />Gravity ❑Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Baas <br />Water <br />wa111111 ons <br />Cement 941b <br />Baas <br />Thickest Thinnest <br />#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 f <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 />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 <br />8 <br />Blank Feet Screen 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 />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 />20 Qltifomia <br />1888 E. Hazelton �Aysn+uoel Stockton��, 95205 209 468-3420 1 F 209 464-0138 <br />10/16/2017 <br />I www.sicehd.com <br />