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SAN JOAQUIEnvironmental Health Department COUNTY Greatness grows here. Mon`iAt'oring Well/Soil Boring Inspection Report v" Date: 1 Inspect O-A CONSTRUCTION Facility Address: 1 -2- r Well Address: Total Depth: WP# Well#: Drilling Rig Type: C3 f (a py, LQ_ Soil Boring#: _ Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: C a�g Screen Length From: To: Driller Onsite: 5'h� Consultant: Filter Pack From: To: Geologist: _� ,- �< Bentonite From: To: 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: COh��1ON cLETioN Method: Ground Surface T Screening Method: 01 grout Verified Chain of Custody: ❑ Yes El No n. n. SPOILS Contamination Noted: ❑ Yes El No = If yes, spoils storage Location: slatted _ 8 s�e5on Covered: ❑ Yes ❑No gravel park If yes, material: GROUTING or DESTRUCTION Total Depth:�l,� Depth to Water: I Itt n' Grout Material: tk-1 //�^ MATERIALS/DEVELOPMENT Gallons of Grout Used: c,s, Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: El Boring Installation)(Boring Destruction Bags iz Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity I_fremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bas gallons Bags Thickest Thinnest uBags Thickest Thinnest 9Bags Bentonite/Cement Mix 3% Mix 5% Mix 2.s s 1 5 10 1 Bentonite per 47 Ib 1.411 2.47 s l0 2 10 20 2 Bentonite per 94 Ib 2.821 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.s4cehd.com