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aau cam, SAN .:JOAQUIN Environmental Health Department z _ COUNTY Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date: J _ " Inspector: I JJ CONSTRUCTION Facility Address: L .�1 Well Address: Total Depth: �� WP#C r :;' ' Well#: Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: El Yes ❑No Drilling Company: _.� IV- Screen Length From: To: Driller Onsite: Filter Pack From: To: Consultant: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: height SAMPLING asovE-r;aouf D CHR_ Holding Temperature: COMPLE 10N PLEnoN Method: Ground Surfact Screening Method: arm Verified Chain of Custody: ❑ Yes ❑No �--n' ft. ft. SPOILS Contamination Noted: ❑ Yes ❑No =" If yes, spoils storage Location: stost�d saran — Covered: El Yes ❑No _ g-v+>ack If yes, material: _ _= GROUTING or DESTRUCTION ,Total Depth: 175 Depth to Water: �6, 1 ?)[) _ t n' Grout Material: 10 , 6eMe*1:F MIX. Gallons of Grout Used: Alf ,r inu(_r MATERIALS/DEVELOPMENT Casing Type: / Well Installation ❑Well Destruction �Tla Blank Feet Screen Feet ❑Boring Installation ❑Boring Destruction _/ I Slot Size: Bags of Cement: METHOD USED - t Bags Sand/Gravel: ( Ct ype/Brand of Bentonite: ElPressure Grout ❑Over Drill \ 1 n Filter Pack Type/Size: ❑ Gravity rTremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bas gallons Bags Thickest Thinnest 9Bags Thickest Thinnest 4Bags Bentonite/Cement Mix 3% Mix 3% Mix 2.5 s 1 s 10 1 Bentonite per 47 Ib 1.41 2.47 5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com