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SAN.]OAQ U I N Environmental Health Department <br /> —COUNTY— <br /> _ .,. i,reatness gro <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: 2 2 _Ins p tor: t CONSTRUCTION <br /> Facility Address: �' r r'L <br /> Well Address: Total Depth: <br /> WP# a Well#: Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: ':T ►�✓C( 7y`- Min 2" Annular EHD Seal Verified: El Yes 11 No <br /> Driller Onsite: �P %Ce' <br /> Screen Length From: To: <br /> Consultant: yv✓ Filter Pack From: To: <br /> Geologist: Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes ❑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: OON'LETION comPLEnON <br /> Method: Ground Surf°o' <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes El No �ft' <br /> ft. <br /> ft. <br /> SPOILS = <br /> Contamination Noted: ❑ Yes ❑No <br /> If yes, spoils storage Location: slotted = . <br /> soon <br /> Covered: ❑ Yes ❑No <br /> If yes, material: _= <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: L7&M)-aJVL' I "I-I larntll n• n" <br /> Grout Material: w - 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 gags iz Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> tAPressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> ` Filter Pack Type/Size: <br /> ❑ Gravity 79Tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> allons Bas gallons Bags <br /> Thickest Thinnest NBags Thickest Thinnest »Bags Bentonite/Cement Mix 3% Mix 3% Mix <br /> 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> s 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 35 70 7 <br /> 20 1 40 8 40 80 `8 <br /> 3 I 4t vV yr t I �2�( �/I '� 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 20 468-3420 1 F 209 464-0138 1 www.s4cehd.com <br />