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c°� SAN �IOAQUIN Environmental Health Department Lint. —COUNTY— Greatness grows here Monitoring Well/Soil Boring Inspection Report Date; D1��7 ) Inspector: SO 11 nay CONSTRUCTION dd Facility Aress. Well Address: Total Depth: WP# 0N\Lktb9j Well#: Drilling Rig Type: Soil Boring#: 7, Drilling Company: J6–Cj.7�[y\. 4y z S6L I CJe5 Min 2" Annular EHD Seal Verified: El Yes ❑No Driller Onsite: Screen Length From: To: Consultant: 1C m7-0 VA 650 614e Filter Pack From: To: Geologist:� Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: WT height SAMPLING AgpyE-GROUND CIHRMTY_ Holding Temperature: COWLETION CCCfAREnON Method: Ground Surfw* Screening Method: P, grout Verified Chain of Custody: ❑ Yes El No —n' tt. ft. SPOILS = Contamination Noted: ❑ Yes ❑No If yes, spoils storage Location: slotted on — B Covered: ❑ Yes ❑No = gr+�sl p..k If yes, material: GROUTING or DESTRUCTION Total Depth: . _ Depth to Water: n — n• Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation KWell Destruction Blank Feet Screen Feet ❑Boring Installation ❑Boring Destruction Slot Size: Bags of Cement: METHOD USED Bags Sand/Gravel: []Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity b4Tremie ❑Other: Type of Method: Water Cement 471b water Cement 941b allons Bas gallons Bags Thickest Thinnest #Bags Thickest Thinnest #Bags Bentonite/Cement Mix 3% Mix 3% Mix 2.5 s 1 ✓ 5 10 1 Bentonite per 47 Ib 1.41 2.47 5 10 2 ✓ 10 20 2 Bentonite per 94 Ib 2.82 4.7 7.5 15 3 V 15 30 3 10 20 4 20 40 4 12.5 25 5 k< 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 H 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sicehd.com