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SAN ,JOAQUIN <br /> Environmental Health Department <br /> —COUNTY— <br /> Ureotness qra.s fere. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: L�2� Inspector: CWAA <br /> k- • CONSTRUCTION <br /> Facility Address: J U 11 '1 U <br /> Well Ad re s: Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes El No <br /> Drilling Company:. 1 V <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: "T'A ( 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 El No casing <br /> If yes, location and distance: height <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: COWLEMN cCOWP�LEnON <br /> Method: owmdSurface T <br /> Screening Method: arm <br /> Verified Chain of Custody: ❑ Yes El No �ft' <br /> ft. <br /> ft. <br /> SPOILS _ <br /> Contamination Noted: ❑ Yes El No <br /> If yes,spoils storage Location: atoned <br /> ,.ction <br /> Covered: ❑ Yes ❑No — <br /> �4: = yrav9t pacFc <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: - ' <br /> Grout Material: " w - <br /> Gallons of Grout Used: MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation *ell Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation ❑Boring Destruction Bags iz Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> []Pressure Grout ❑Over Drill <br /> Filter Pack Type/Size: <br /> ❑ Gravity ATremie ❑Other: Type of Method: <br /> Water Cement 47 lb Water Cement 94 lb <br /> allons Bas gallons Bags <br /> Thickest Thinnest 4'Lai.: Thide<t Thinnest ;7 Bags Bentonite/Gement NliX r.4' mix rl%s MIX <br /> 2.5 5 1 s _ 1 1u 1 Bentonite per 47 Ib 1 1.4111 2.47 <br /> 5 10 2 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 6 30 60 6 <br /> 17.5 35 1 7 35 70 7 <br /> 20 40 8 1 40 1 80 1 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.socehd.com <br />