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SA N J OA Q U I N Environmental Health Department <br /> COUNTY <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspector: S CONSTRUCTION <br /> Facility Address: <br /> Well Address: Total Depth: <br /> WP# ) Well#: Drilling Rig Type: <br /> Soil Boring#: wl 1 2- 13 <br /> Drilling Company: Min 2" Annular EHD Seal Verified: El Yes ❑No <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: <S Filter Pack From: To: <br /> Geologist: r�/'p./` 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: height <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: cot�w�l°N oc PiFno_N <br /> Method: around Surface <br /> Screening Method: grow <br /> Verified Chain of Custody: ❑ Yes El No �ft. <br /> ft. <br /> tt. <br /> SPOILS = <br /> = o <br /> Contamination Noted: ❑ Yes El No = <br /> = o <br /> If yes, spoils storage Location: <br /> tec.on = 3 <br /> Covered: ❑ Yes ❑No = g—w t <br /> ack <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: 3• �-C 1: <br /> Depth to Water: <br /> Grout Material: Nea't"t[�y�Q,VIZ MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> ❑ Slot Size: <br /> Boring InstallationlBoring Destruction Bags Size: <br /> Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> ,Gravity ❑Tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 94 lb <br /> allons Bas eallons Bags <br /> Thickest Thinnest 0Bags Thickest Thinnest 9Bags 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 50 515 30 6 30 60 6 <br /> ll <br /> 17.5 35 7 35 70 7 �6 (� (41 &SJ <br /> 20 40 8 40 80 8 J <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.s*cehd.com <br />