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�a SAN.=:IOAQUIN Environmental Health Department <br /> —COU NTY–- <br /> 'c?c�Fba�`r. Greotness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: L Inspector: CONSTRUCTION <br /> Facility Address: 2 <br /> Well Address: _ Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: - Min 2"Annular EHD Seal Verified: ❑ Yes ❑No <br /> Drilling Company ( l <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: 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 ❑No casing <br /> If yes, location and distance: height <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: CONFLET10N COOMPLEMN <br /> Method: G=na Surfarn <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes ❑No �tt' <br /> tt. <br /> ft. <br /> SPOILS ; <br /> Contamination Noted: ❑ Yes ❑No <br /> If yes,spoils storage Location: slottad <br /> on <br /> Covered: ❑ Yes El No = 9-+P-ack <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: T. <br /> Depth to Water: Y)1.) ,Y�'c. tt — tt' <br /> Grout Material: r. <br /> Gallons of Grout Used: (e, MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> ❑Boring Installation N�BSlot Size: <br /> oring Destruction Bags Size: <br /> Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity FTremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 94 lb <br /> allons Bas vallons Bags <br /> Thickest Thinnest 9Bags Thickest Thinnest J1 Bags 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 � 'q4 Bentonite per 94 Ib 2.82 4.7 <br /> 7.5 15 3 15 Spay <br /> 10 20 4 20 40Re <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s*cehd.com <br />