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SAN J 0 A 0 U I N <br /> Environmental Health Department <br /> " COUNTY <br /> °9cr Greatness grows here. <br /> 02— <br /> MonitoringA/V4 <br /> Well/Soil Boring Inspection Report <br /> Dater7 � Inspector: /a QNSTRUCTION <br /> Facility Address: <br /> Well Address: Total Depth: <br /> WP#00 q Well#: Drilling Rig Type: <br /> Soil Boring#: a <br /> Drilling Compan WK Min 2" Annular EHD Seal Verified: El Yes El No <br /> Driller Onsite: AV Screen Length From: To: <br /> Consultant:WtsdLD <br /> / 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: CONFLET10N COMPLETION <br /> Method: G=nd Surface <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes ❑No -i--n' <br /> n. <br /> n. <br /> SPOILS <br /> Contamination Noted: ❑ Yes El No <br /> If yes, spoils storage Location: Sion" c: <br /> s <br /> on <br /> — <br /> Covered: ElYes El No <br /> .«: = gravwl pad` <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth:��� __ <br /> Depth to Water: -Ltt' <br /> IF <br /> Grout Material: Ae <br /> Gallons of Grout Used: �30 dal lows MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation E�Boring Destruction Bags of Cement: <br /> METHOD USED l AyytC 1 ; k . Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> ❑ Gravity RTremie ❑Other: Type of Method: <br /> Water Ceme 471 Water Cement 941b <br /> allons Ba gall ons Bags <br /> Thickest Thinnest aBags Thickest Thinnest uBags Bentonite/Gement 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 35 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 40 80 8 <br /> 010/16/2017 <br /> E <br /> 1868 . Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />