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Environmental Health Department <br />—COUNTY <br />' �R1` Greutness groris herc, <br />Monitoring Well/Soil Boring Inspection Report <br />Dateakdzp Inspector: %' CONSTRUCTION <br />Facility Ad ress:Z?2( --6gm <br />Well Address: Total Depth: <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#: , <br />Drilling Company: �r Min 2" Annular EHD Seal Verified: ElYes ❑No <br />Driller Onsite: Screen Length From: To: <br />Consultant: -p Filter Pack From: To: <br />Geologist: Bentonite From: To: " <br />Grout From: To: <br />Public Water System Onsite: ❑ Yes ONo <br />Domestic Well Onsite: <br />If yes, location and distance: <br />❑ Ye <br />❑No <br />SAMPLING <br />Water <br />palluns <br />Cement 941b <br />Bags <br />Holding Temperature: <br />#Bags <br />Thickest Thinnest <br />Method: <br />2.5 <br />5 <br />Screening Method: <br />5 <br />10 <br />Verified Chain of ustody: <br />❑ Yes <br />❑No <br />SPOILS <br />10 <br />20 <br />Contamin tion Noted: <br />❑ Yes <br />❑No <br />If ye , spoils storage Location: <br />15 <br />30 <br />Cov ed: <br />❑ Yes <br />❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: _ <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 />WGravity Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />palluns <br />Cement 941b <br />Bags <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 />10 <br />5 <br />3 <br />4 <br />15 <br />30 <br />3 <br />20 40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 1 <br />30 1 <br />6 <br />30 <br />60 <br />6 <br />17.5 1 <br />35 1 <br />7 <br />35 <br />70 <br />7 <br />20 1 <br />40 1 <br />8 1 <br />40 <br />80 <br />8 <br />P <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />3fcasing <br />T <br />T height • <br />R fm T <br />ASOVE-GROUND c iRmw-Box <br />COWLETION <br />COMPLETION <br />G cUnd Surface — --- <br />grout <br />ft. <br />ft. <br />tc. _ <br />� — a <br />w <br />_ o <br />slotted w S <br />tatJan - _ <br />g—w Pack <br />"a <br />—ft `_ — <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 (Nix 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.sicehd.com <br />