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p[o4W C• <br /> --a. A IN Environmet,__I Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspec r: x � `� CONSTRUCTION <br /> Facility s : 1 f�ddre <br /> Well Address: Total Depth: <br /> WP# C� c( _Well#: Drilling Rig Type: <br /> Soil Boring#: Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br /> Drilling Company: 7 <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: UJ Filter Pack From: To: <br /> Geologist: Bentonite From: To: <br /> Grout From: To: <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: Iff <br /> height <br /> SAMPLING wove-GROUND CHRMY-BOX Holding Temperature: cowiLrTion coe4ai.Enoti <br /> Method: ckwnasutac �-- <br /> Screening Method: ora l <br /> Verified Chain of Custody: ❑ Yes ❑No a' <br /> tt. <br /> SPOILS <br /> Contamination Noted: ❑ Yes MIN = <br /> If yes, spoils storage Location: �brcad <br /> Covered: ❑ Yes ❑No — IfiVAPack <br /> If yes, material: 5 \ - <br /> I - <br /> GROUTING or DESTRUCTIOP Total Depth: <br /> Depth to Water: tt. tt. <br /> Grout Material: MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: 7, <br /> �7 Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> El Boring Installation oring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill <br /> �� Filter Pack Type/Size: <br /> V Gravity UKremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> Ilons Bags Rallons Bags <br /> Thickest Thinnest #Bags Thickest Thinnest #Bags BentonitelGement Mix 3°/a MIX 5% MIX <br /> 2.5 5 1 s 10 1 Bentonite per 47 lb 1.41 2.47 <br /> s 10 z 10 ze z Bentonite per 941b 2.62 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 8 40 80 8 <br /> 33 I 10/16/2017 <br /> 1868 E. Hazelton Menu I Stoct n, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />