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°¢v SAN JOAQUIN <br />COUNTY <br />�cgcrFoaN�¢ Greatness grows here. <br />r� �J Monitoring Well/Soil <br />Bo <br />Date: !i �(�� Inspector: -YID 4 <br />Facility Address: LJ SS '�St040yr - 4:y -e <br />Well Address: <br />WP# 00 � j Well#: <br />Soil Boring#: Z <br />Drilling Company: <br />Driller Onsite: <br />Consultant: a� S d!/%� <br />Geologist: <br />Public Water System Onsite: ❑ Yes El No <br />Domestic Well Onsite: ❑Yes ❑No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: El Yes ❑No <br />SPOILS <br />Contamination Noted: El Yes El No <br />If yes, spoils storage Location: <br />Covered: El Yes El No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: Oi�1R— <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />El Boring <br />Installation�oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />^�I Gravity LN .1 <br />❑Other: <br />Water Cemetf <br />allons <br />b <br />Bas <br />Water <br />allons <br />Cement 941b <br />Ba s <br />Thickest <br />Thinnest <br />gBags <br />Thickest <br />Thinnest <br />ltBags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />30 <br />60 <br />6 <br />15 <br />30 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />40 <br />80 <br />8 <br />20 <br />40 <br />8 <br />1868 E. Hazelton Avenue Stockton, California 95205 <br />Environmental Health Department <br />Departmentnt <br />ring Inspection Report <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />COMPLETION <br />From: <br />From: <br />From: <br />From: <br />❑ Stove Pipe <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />casing <br />heigh <br />Ut <br />ABOVE-GROND CHF3ISTY43OX <br />COWLETION COMPLETION <br />Ground surfx+ <br />grout <br />ft. <br />ft* <br />ft. <br />m <br />I • rJ � f stottvd <br />socton =_ <br />VI�+I� <br />rrHsh— _ <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank <br />Size: <br />Slot <br />Bags of Cement: <br />Feet Screen <br />Feet <br />Bags Sand /Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />BentonitelCement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />10/16/2017 <br />T Of) <br />9 468-3420 � F 209 464-0138 � www.sicehd.com <br />10/16/2017 <br />T Of) <br />9 468-3420 � F 209 464-0138 � www.sicehd.com <br />