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D N� <br /> .; . SANoJOAQUIN Environmental Health Department <br /> `:._ • < <br /> _.: <br /> Greatness grows Fer <br /> kde2ss4: w1.I <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: nspector: � CONSTRUCTION <br /> FaciltyA <br /> WellAddr s: Total Depth: <br /> WP# d Well#:_AgEd Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: 1 Min 2"Annular EHD Seal Verified: ❑Yes ❑No <br /> Driller Onsite: �t 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 ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑Yes ❑No <br /> casing <br /> If yes,location and distance: <br /> SAMPLING . AaovE-r4ROUNo <br /> Holding Temperature: coh.PLETIONSOXNX <br /> Method: c�;ra swt�o COh1PLy9 <br /> Screening Method: gran <br /> Verified Chain of Custody: ❑ Yes ❑No e. <br /> n. <br /> SPOILS -- ' <br /> = Y o. <br /> Contamination Noted: ❑Yes ❑No <br /> z <br /> If yes,spoils storage Location: <br /> Covered: ❑Yes ❑No 4acyon <br /> If yes,material: _ <br /> GROUTING or DESTRUCTION Total Depth:___ = ,. <br /> • Depth to Water: ctt- <br /> Grout Material: <br /> Gallons of Grout Used: MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> _ / Slot Size: <br /> ❑Boring Installation fdBoring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout Dover Drill Type/Brand of Bentonite: <br /> �� Filter Pack Type/Size: <br /> El Gravity tXlremie ❑Other: Type of Method: <br /> Water Cement4711, Water oement94lb <br /> gallons Be allons Be <br /> Thickest Thinnest pBags 7hlckest Thinnest 4Bags BentoniteiGement Mix 3,/.Mix 5%Mix <br /> zs s 1 5 10 1 Btentonite per 47 lb 1 1.41 2.47 <br /> 1B z 10 z0 z <br /> 7,,5 5 SS Bentonite per 941b 2.82 4.7 <br /> 1 3 30 3 � <br /> 10 20 4 20 40 4 <br /> 11.5 25 5 35 50 5 <br /> 15 30 6 30 60 6 <br /> 17.5 a5 7 35 70 7 <br /> 20 40 a 40 ea 3 <br /> z l5 D .3 10/16/2017 <br /> 1868 E. Hazelton Avenue I toc on, Cal forma 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />