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SANIIOAQUI[l <br /> Environmental Health Department <br /> —COUNTY— <br /> p 1 � G'eotness groes herr <br /> Monitoring Well/Soil Boring Inspection (Report <br /> Date: 1V Inspector: CONSTRUCTION <br /> Facility Address: M&bW J <br /> Well Address: Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes El No <br /> Drilling Company: MN✓VA, � Ca"'A\ Screen Length From: To: <br /> Driller Onsite: 4.5� <br /> Consultant: Filter Pack From: To: <br /> Geologist: 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 distances / \ „�� ,Jt���� iheight <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: GOION ;aN <br /> Method: Ground Surface <br /> Screening Method: prlout <br /> Verified Chain of Custody: ❑ Yes El No ct. <br /> �t. <br /> tt. <br /> SPOILS <br /> R=_ <br /> Contamination Noted: ❑ Yes ❑No <br /> .K' C <br /> If yes, spoils storage Location: <br /> Covered: ❑ Yes EJ No = <br /> If yes, material: <br /> GROUTING or ESTRUCTIO Total Depth: <br /> Depth to Water: $�� `t _ tt• <br /> Grout Material:AA>JCDNS&L MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> ❑Well Installation Well Destruction Blank Feet Screen Feet <br /> ❑Boring Installation ❑BSlot Size: <br /> oring 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 lOther: 9 Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> allons Bas allons Bags <br /> Thickest Thinnest 9Bags Thickest Thinnest Bags Bentonite/Cement Mix 3% Mix 5%Mix <br /> 2.5 5 1 5 1 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 <br /> 7.5 15 3 15 s0 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 35 735 70 7 <br /> 20 40 8 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />