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_} SA N-J OAQ U I N Environmental Health Department Q " W r' `) —COUNTY— Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date: l Inspector: wom , CONSTRUCTION Facility Address: Well Address: a�'�' Total Depth: WP#_ ()03 Well#: Drilling Rig Type: Soil Boring#: r � Drilling Company: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Driller Onsite: �G �� }� PIC; Screen Length From: To: Consultant: Filter Pack From: To: C {.R 1 2-e r Bentonite From: To: Geologist: ill Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: CoWP�noN �t.EnoN Method: Ground Sumacs Screening Method: grout Verified Chain of Custody: ❑ Yes El No tt. ft. SPOILS K Contamination Noted: ❑ Yes El No C If yes, spoils storage Location: sacyon Covered: ❑ Yes ❑No = g-vw P--k If yes, material: GROUTING or DESTRUCTION Total e�ptl _b5� . Depth to Water: ft. tt. Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: IJ ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation KBoring Destruction I('� Bags of Cement: METHOD USED v Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill ✓✓ Filter Pack Type/Size: ❑ Gravity ,�ITremie ❑Other: Type of Method: Water l/CCeement 471b Water Cement 94 lb allons Bas gallons Bags Thickest Thinnest 9Bags Thickest Thinnest ltBags Bentonite/Cement Mix 3% Mix 5% Mix 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 s 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.socehd.com