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• �U r: <br /> SAN J OAQ U I N Environmental Health Department <br /> " - COUNTY— <br /> Greatness grows here. <br /> Monitoring -Well/Soil Boring Inspection Report <br /> Date: z I ( 1 J s ecto : -1 CONSTRUCTION <br /> Facility Address: <br /> Well Address: Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: R <br /> Drilling Company: W �f CpGIS-t" Min 2"Annular EHD Seal Verified: El Yes []No <br /> Driller Onsite:_�Y�f3. Screen Length From: To: <br /> ( y� <br /> Filter Pack From: To: <br /> Consultant: &ZFf <br /> Geologist: MASK Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes El No casing <br /> If yes, location and distance: height <br /> —Ef <br /> SAMPLING ABOVE-GROUND <br /> CO <br /> Holding Temperature: fOWiIoN COMPLETION <br /> Oh1PLETION <br /> Method: Ground Surface <br /> Screening Method: ori <br /> Verified Chain of Custody: ❑ Yes L1 No <br /> ft. <br /> tt. <br /> SPOILS <br /> r: <br /> A C <br /> Contamination Noted: ❑ Yes El No <br /> If yes, spoils storage Location: sto�ad <br /> = B <br /> on � — <br /> Covered: ❑ Yes L1 No -7 _ graw+Pack <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: n• tt' <br /> Grout Material: -qt CQ <br /> MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> ❑Boring Installation I$BSlot Size: <br /> oring Destruction Bags Size: <br /> Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> 1 Gravity ❑Tremie ❑Other: Type of Method: <br /> II Water Cement 47 lb Water Cement 941b <br /> gallons Bas gallons Bags <br /> Thickest Thinnest 1J Bags Thickest Thinnest uBags 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 30 310 20 4 20 40 4 ( \ 1 <br /> 12.5 25 5 25 50 5 ( ` ball `� kJ I WCtf'C! <br /> 15 30 6 30 60 6 <br /> 105 35 7 70 7 40 8 40 0 8 2 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />