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SANJ0AQUIN Environme, I Health Department <br /> _. . —COUNTY— <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspector: CONSTRUCTION <br /> Facility Address: yr?:;t y 4 c. 0 . <br /> Well Address: Total Depth: <br /> WP# `-�\ Well#: Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: �, Min 2"Annular EHD Seal Verified: El Yes El No <br /> g p Y: v.�Sc die oyns� <br /> Driller Onsite: ���� Screen Length From: To: <br /> Filter Pack From: To: <br /> Consultant: <br /> Geologist: -� �,,. ,p ���,, g Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: O'Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes NNo casing <br /> If yes, location and distance: height <br /> SAMPLING v 1 ABOVE-GROUND CRAM-rW30X <br /> Holding Temperature: cohrLErjoN COMPLETION <br /> Method: Ground Surface + <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes ❑No 4l, ft. <br /> ft. <br /> ft. <br /> SPOILS `P <br /> m = e <br /> Contamination Noted: ❑ Yes ❑No s=` <br /> If yes, spoils storage Location: slo — - <br /> n <br /> Covered: ElYes ❑No � =_ <br /> grx"pack <br /> If yes, material: . <br /> GROUTING or DESTRUCTION Tota Depth: <br /> Depth to Water: 2�, �' ft' <br /> Grout Material: MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: r S L <br /> r— Casing Type: <br /> []Well Installation Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation ❑Boring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> 'IKPressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity )�Tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> allons Bas gallons Ba s <br /> Thickest Thinnest tlBags Thickest Thinnest #Bags Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 .s- ::= s 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 is 3 is 30 3 <br /> 10 20 4 20 40 4 <br /> 12.s 25 5 2s so 5 <br /> 15 30 6 30 60 6 1� Lr'*0—!i <br /> 17.5 35 7 35 70 7 <br /> 20 40 a 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.smcehd.com <br />