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SAN 10AQUIN <br /> Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspector: A. CONSTRUCTION <br /> Facility Address: <br /> Well Addres : Total Depth: (/ <br /> WP# _ Well#: Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: 1/ Min 2"Annular EHD ❑ []No <br /> Verified: Yes No <br /> Driller Onsite: A Screen Length From: To: <br /> Consultant: Filter Pack From: To: <br /> Bentonite From: To: <br /> Geologist: <br /> Grout From: To: Q <br /> Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes ❑No casing <br /> If yes, location and distance: height <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: OOWLETION comPPLEnooN <br /> Method: Gmune Surface <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes El No <br /> it. <br /> SPOILS <br /> Contamination Noted: ❑ Yes L1 No <br /> If yes,spoils storage Location: slotted <br /> sac5on <br /> Covered: ❑ Yes ❑No = c-w+pack <br /> If yes, material: '11 <br /> GROUTING or DESTRUCTION Total Depth: � : • _ L <br /> Depth to Water: � � _ n- tt. S i <br /> Grout Material: <br /> � MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: � <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation„�Boring Destruction Bags of Cement: <br /> METHOD USED ���� Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> -Gravity ElTremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> allons Bas gallons Bags <br /> Thickest Thinnest 9Bags Thickest Thinnest 11 Bags Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 <br /> 7.5 15 3 15 30 3 <br /> 10 20 4 20 40 4 <br /> 12.5 25 5 25 50 5 <br /> 15 30 6 30 60 6 <br /> 17.5 35 7 35 70 7 <br /> 20 40 B 40 80 8 <br /> -7.0 •b � C, 2 .5 0 t 1s, 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sicehd.com <br />