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U IV co SAN�J0A0UIN yJ —COUNTY– Environmental Health Department a cw0P' Greatness grows here Monitoring Well/Soil Boring Inspection Report Date: �I�2�Zy Inspector: v, CONSTRUCTION Facility Address: Well Address: 1�1 \ N1cC1v„ c:tiw i �[v �, Total Depth: ,V WP# EQ C d I t1;t Well#: Drilling Rig Type: C ` Soil Boring#:_"'j-0'1 Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Ccne fg i 4. Cr L',y Screen Length From: To: Driller Onsite: AC it< Filter Pack From: To: Consultant: 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 AWVE-GROUND Holding Temperature: COWPLETION COMPMN tE Method: G=ndSurf"' + " Screening Method: oraLd Verified Chain of Custody: ❑ Yes ❑No -�---n' it. ft. SPOILS a Contamination Noted: ❑ Yes ❑No = r If yes,spoils storage Location: aloud aeon Covered: ❑ Yes El NoZ EE_ gra„lw pacK If yes, material: GROUTING or DESTRUCTION Total Depth: A"'% k� Depth to Water: x• 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: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: ❑ Gravity 1�ITremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bas eallons Bags Thickest Thinnest 9Bags Thickest Thinnest 9Bags Bentonite/Cement Mix S% Mix 5% Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 5 10 (Z' 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 T 209 468-3420 1 F 209 464-0138 www.sicehd.com