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SQN:=IOQQUIN Environmental Health Department —COUNTY— Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date: %Z10 Inspector: CONSTRUCTION Facility Address: Well Address: Total Depth: WP# Well#: Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Driller Onsite: 5_ Screen Length From: To: Consultant: Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes WO COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes %No casing If yes, location and distance: ` height —ww' SAMPLING �1�b AWVE-GROUND Holding Temperature: COWLS ON GOOMPLETiON Method: Ground Sutacs Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No ft. ft. ft. ft. SPOILS — o Contamination Noted: ❑ Yes i7No If yes, spoils storage Location: slotted n Covered: El Yes Yes o sooX' If yes, material: ~Y. GROUTING or DESTRUCTION Total Depth: Depth to Water: ltx ft. IF h' Grout Material: N V�c'c ��, �Y� Gallons of Grout Used: MATERIALS/DEVELOPMENT Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑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 LTremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bas Rallons Bags Thickest Thinnest tlBags 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 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 20 140 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.sicehd.com