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SAN-JOAQUIN Environmental Health Department ---COUNTY— �cti, `P' Greatness grows here Monitoring Well/Soil Boring Inspection Report Date: I b Inspector: 1�VvCA5 CONSTRUCTION Facility Address:_ 1,jy`3 6(k IQ A,.k— r\tS) Well Address: Total Depth: WP# "Oyl_!�� Well#: Drilling Rig Type: Soil Boring#: ON Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Driller Onsite: J Screen Length From: To: Consultant: Filter Pack From: To: Geologist: "Y4 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: height SAMPLING ABOVE-GROUND Holding Temperature: CONFLEf1ON EnorXi Method: Ground Surface Screening Method: alp Verified Chain of Custody: ❑ Yes El No tt. tt. SPOILS Contamination Noted: ❑ Yes El No If yes, spoils storage Location: allotted aeon Covered: ❑ Yes ❑No = g-w+pacic If yes, material: GROUTING or DESTRUCTION Total Depth: 1T. : • __ Depth to Water: �m k Grout Material: N&V NOW MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation ❑Boring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: ❑ Gravity ❑Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 94110 allons Bas gallons Bags Thickest Thinnest 9Bags Thickest Thinnest ttBags Bentonite/Cement Mix 3% Mix 5%Mix 2.5 s 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 5 v 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.sacehd.com