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SAN )OAQ U I N Environmental Health Department t —COUNTY— Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date: L 5 Inspector: ^ r4..d CONSTRUCTION Facility Address: S(o()i P Cf h c "t, Well Address: Total Depth: WP# OD 52i R _Well#: Drilling Rig Type: Soil Boring#:_ 1� Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: ' I Screen Length From: To: Driller Onsite: S Consultant: C.W'Py' Filter Pack From: To: Geologist: J© KY- 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: WT height SAMPLING AWVE-GROUND Holding Temperature: COMPLETION COMPLETION Method: Grvund S"n'°' Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No .�_ft. ft. fi. SPOILS = o Contamination Noted: ❑ Yes ❑No a` _ If yes, spoils storage Location: stottnd = B Covered: ElYes El No sat-Son If yes, material: _ GROUTING or DESTRUCTION Total Depth: .= Depth to Water: — ft• — ft Grout Material: Q,t CLj.py 1,10 MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation []Well Destruction Blank Feet Screen Feet ❑Boring Installation�jSlot Size: Boring Destruction Bags Size: Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 94 lb allons Bas gallons Bags Thickest Thinnest #Bags Thickest Thinnest #Bags Bentonite/Cement Mix 3% Mix 5% Mix 2.5 5 1 5 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 �{� au D ns WCL it� i (1"I I%0) �� 15 30 6 30 60 6 v G 17.5 35 7 35 70 7 J 20 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 www.sicehd.com