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SAKJ0A0UIN <br /> —cou NTY— Environmental Health Department <br /> �cLc,Foa�>P Greatness grows fie,e <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: 2 Insect r: CONSTRUCTION <br /> Facility Ad ress. �. <br /> Well Address: Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: g"� <br /> Drilling Company: � Min 2"Annular EHD Seal Verified: El Yes El No <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: Con j Filter Pack From: To: <br /> Geologist: r 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 casing <br /> If yes, location and distance: WT <br /> height <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: CONFLEnON snoN <br /> Method: G=nd Surf"'' <br /> Screening Method: grout <br /> 01 <br /> WA <br /> Verified Chain of Custody: ❑ Yes ❑No <br /> ft. <br /> ft. <br /> SPOILS <br /> Contamination Noted: ❑ Yes El No <br /> C <br /> If yes, spoils storage Location: <br /> L1C7on — B <br /> Covered: ❑ Yes ❑No <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: =_ <br /> Depth to Water: -) tt• n' <br /> Grout Material: nlC CeW'0r17- MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> 13 <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation *oring Destruction Bags iz Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> �-9[Gravity ❑Tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 94 lb <br /> gall s Bas g20 <br /> ns Bags <br /> Thickest Thinnest 9Bags Thinnest »Bags Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 5 1 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> 5 10 2 20 2 Bentonite per 94 Ib 2.82 4.7 <br /> 0 7.5 15 3 30 3 <br /> 10 20 4 40 4 <br /> 12.5 25 5 25 50 5 <br /> 15 30 6 30 60 6 <br /> 17.5 35 7 35 70 7 <br /> 20 40 1 8 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sucehd.com <br />