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SAKJOA <br /> UIN <br /> � Environmental Health Department <br /> —COUNTY <br /> �4 Greatness grows hekc <br /> Monitoring Well/Soil Boring Inspection Report on <br /> Date:� Inspector: J . \ QCONSTRUCTION <br /> Facility ddAress: <br /> Well Address: Total Depth: <br /> WP# u)f(O4 i ?_q-4- Well#: Drilling Rig Type: <br /> Soil Boring#: < < Min 2"Annular EHD Seal Verified: El Yes ❑No <br /> Drilling Company: 6r\ 1 Y6uriltC <br /> Screen Length From: To: <br /> Driller Onsite: <br /> Consultant: Filter Pack From: To: <br /> Geologist: f Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe El Christie Box <br /> Domestic Well Onsite: ❑ Yes []No casing <br /> If yes, location and distance: height <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: 006PLEriON cLEnoN <br /> Method: GroundSurfaos + _ <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes ❑No <br /> n. <br /> n. <br /> SPOILS = <br /> Contamination Noted: ❑ Yes ❑No <br /> If yes, spoils storage Location: slotted = B <br /> sac�on <br /> Covered: ❑ Yes ❑No = Vs„a Pack <br /> If yes, material: x <br /> :s — <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: "_ UJ(jl �,�- n• - tt' <br /> Grout Material: Y"-ea 61e"14 <br /> l,T <br /> MATERIALS/DEVELOPMENT <br /> MGallons of Grout Used: <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation 1XBoring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill <br /> Filter Pack Type/Size: <br /> *Gravity Tremie ❑Other: Type of Method: <br /> Water Cement 471b water Cement 941b <br /> allons Bags gallons Bags <br /> Thickest Thinnest uBags Thickest Thinnest aBags Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 <br /> 7.5 15 3 15 3 <br /> 10 20 4 20 40 1 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 8 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 www.s*cehd.com <br />