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SAN,-�JDAQUIN ' —C.O U N T Y°-- Environmental health Department Greatness grows here- Monitoring Weil/Soil Boring Inspection Report Date: I IS 120 Inspector: c-&(v lc�vtiC' CONSTRUCTION Facility Address: C lei;we ll Well Address: Total Depth:�S p WP# L(, l COS Well#: Drilling Rig Type: � l Soil Boring#: I- Drilling Company: (oec ^�x Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Driller Onsite: N'I Screen Length From: To: Consultant: QG((, Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: 77height SAMPLING Holding Temperature: � ' ' r �' �F�o Method: Grodrd Swfacs Screening Method: Verified Chain of Custody: ❑ Yes ❑No f SPOILS • Contamination Noted: ❑ Yes ❑No If yes, spoils storage Location: ' started s2C3on _ -a Covered: ❑ Yes ❑No r If yes, material: GROUTING or DESTRUCTION Total Depth: S i Depth to Water: 4� - "- Grout Material- kla MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Size: ❑Boring Installation I1BSlot Size: oring Destruction Bags Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout Dover Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity BTremie ❑Other: Type of Method: Water, eme �47lb Water Cement94lb '-gallons Baas gallons Bags Thickest Thinnest #Bags Thickest Thinnest #Bags 13entonite/Cement Stix 3% Mix 501, Mix 2.5 5 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 is 30 3 10 20 4 20 4D 4 ` 12.5 25 5 25 50 5 15 30 1 6 30 60 6 17.5 35 7 35 70 7 20 40 B 40 00 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sicehd.corn