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SAN JOAQUIN Environmental Health Department COUNTY - Mo,n�it�oring Well/Soil Boring Inspection Report Dater Inspector: ✓� CONSTRUCTION Facility Address: ?I irP /, Well Address: Total Depth: " 0 C P T WP# ` q O � I Well#: Drilling Rig Type: 1 Soil Boring#: CP,— „ cL C 2 Min 2 Annular EHD Seal Verified: El Yes ❑No Drilling Company: Driller Onsite: ar , Screen Length From: To: �� Filter Pack From: To: Consultant: '�cl 1� �C ,� M , Geologist: � +�+8, Bentonite From: To: ti,. 00 Grout From: To: Public Water System Onsite: ❑ Yes 11 No COMPLETION ❑ stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: COMPLETION COMPLETION Method: Ground Surlacs Screening Method: grout Verified Chain of Custody: ❑ Yes El No ft. _ SPOILS u: m Contamination Noted: ❑ Yes El No = c / If yes, spoils storage Location: .toted aac'on Covered: ❑ Yes ❑No = g-4 pack If yes, material: sr GROUTING or DESTRUCTION Total Depth:_ = Depth to Water: n n' Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation ❑Boring Destruction Bags of 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 alIII ons Bas Rallons Bags Thickest Thinnest #Bags Thickest Thinnest PBags Bentonite/Gement 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 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 1 www.s'cehd.com