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SAN J OA Q U I N Environmental Health Department <br /> COUNTY <br /> �`ctiFoai�pr, Greatness grows her, <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: 2 "I Inspector: CONSTRUCTION <br /> Facility Address: <br /> Well Address: Total Depth: <br /> WP# © ?J� Well#: Drilling Rig Type: <br /> Soil Boring#: <br /> C A1 Min 2" Annular EHD Seal Verified: El Yes Ll No <br /> Drilling Company: 6 <br /> Driller Onsite: •J Screen Length From: To: <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 distance: WT <br /> height <br /> SAMPLING ABOVE-GRCUND <br /> Holding Temperature: COWLE-DON CGWIPLE'ncN <br /> Method: Carbone Sumacs <br /> Screening Method: orOut <br /> Verified Chain of Custody: ❑ Yes ❑No �ft' <br /> n. <br /> ft. <br /> SPOILS = <br /> Contamination Noted: ❑ Yes ❑No = r <br /> If yes, spoils storage Location: .zonae <br /> arc'cn _ <br /> Covered: ❑ Yes ❑No = 9, <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total De '� t 20D <br /> Depth to Water: <br /> Grout Material:1 ►� �(i 0� �bl <br /> Gallons of Grout Used: MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ell Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> Boring Installation L1 Boring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity �Tremie ❑Other: Type of Method: <br /> Water ll Cement 471b water Cement 941b <br /> allons Bas vallons Bags <br /> Thickest Thinnest 9Bags Thickest Thinnest #Bags Bentonite/Cement Mix 3% MIX 3% MIX <br /> 2.5 5 1 5 to 1 Bentonite per 47 Ib 1 1.411 2.47 <br /> 5 10 10 20 2 Bentonite per 94 Ib 2.821 4.7 <br /> 7.5 15 3 15 30 3 <br /> 10 20 4 20 40 4 <br /> 12.5 25 5 25 50 5 <br /> 15 30 b 30 70 7 0 b <br /> 35 35 7e i Cbrotkl WcaDr <br /> 17.5 7 <br /> 20 40 8 40 80 8 <br /> I� i�/201 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.tcom <br />