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} t SANTIOAQUIN <br />Environmental Health Department <br />—COUNTY <br />�s roQ�P' G-eotness grows here. <br />/ Monitoring Well/Soil Boring Inspection Report <br />Date: G Inspector: �r� CONSTRUCTION <br />Facility Address: 2 g -(%G <br />Well Address: Total Depth: <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#: V Min 2" Annular EHD Seal Verified: ❑ Yes El No <br />Drilling Company: <br />Driller Onsite: 1. <br />Screen Length <br />From: <br />To: <br />Consultant: % <br />Filter Pack <br />From: <br />To: <br />Geologist: // <br />Bentonite <br />From: <br />To: <br />Public Water System Onsite: ❑ Yes No <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 />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth:_ <br />Depth to Water: tl' %1 J� <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity *remie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />uBags <br />Thickest Thinnest <br />4Bags <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 />17.5 <br />35 <br />7 <br />35---F <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />1 80 <br />8 <br />Grout <br />rnimPi FTIOIV <br />From: <br />❑ Stove Pipe <br />To: <br />❑Christie Box <br />casing <br />height <br />ABOVE -GROUND Ctimsw-BOX <br />COMPLETION COMPLETION <br />Ground Surfak* <br />or«rt <br />ft. <br />it. <br />zk — o <br />w <br />0 <br />slotted <br />asction - -' <br />— PaCK <br />H <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 <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 />"RV6 *t 1141 <br />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34(20 1 F 209 46`4-0138 1 www.sicehd.com <br />