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'� c SANJOAQUIN Environmental Health Department —COUNTY----- Greatness COUNTY —Greatness grows here. / Monitoring Well/Soil Boring Inspection Report Date: Inspector: CONSTRUCTION Facility Address. w Well Address: Q Total Depth: WP# Well#: Drilling Rig Type: cw-mLi--V Soil Boring#: 1- R� Min 2"Annular EHD Seal Verified: ❑ Yes []No Drilling Compan : 2 `ZxvL Driller Onsite: � Screen Length From: To: Consultant: Filter Pack From: To: Geologist: �JU��po Bentonite From: To: �- Grout From: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes El No casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: CONFLETION cCOMPLEnciN Method: G=nd Surface Screening Method: grout Verified Chain of Custody: ❑ Yes El No �--n' tt. n. SPOILS N; -d Contamination Noted: ❑ Yes ONO r" If yes, spoils storage Location: _r slotted —2S- section a• = 3 Covered: L1 Yes ❑ g-vlw P--K If yes, material: GROUTING or DESTRUCTION Total Depth: Depth to Water: 2-t 1 —5/; n• n' Grout Material:�0 0 _�m 6 �1 Used. MATERIALS/DEVELOPMENT Gallons of Grout Use 4S Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: El Boring Installation ITBoring 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 ement 471b Water Cement 941b allons Bas gailons Bags Thickest Thinnest uBags Thickest Thinnest #Bags Bentonite/Cement 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 2Ikgs W U WA-ON- 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 www.sicehd.com