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SANPJOAQUIN <br /> Environmental Health Department <br /> —COUNTY----- <br /> �r9eiFoaN`� Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> C- <br /> Date: Inspector: 30_ i CONSTRUCTION <br /> Faciliity Ad ress: <br /> Well Address: Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: Q <br /> Min 2" Annular EHD Seal Verified: El Yes ❑No <br /> Drilling Company: 0 <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: 'U\fm 'E)M QA i'Vd L'1mD. Filter Pack From: To: <br /> Geologist: <br /> Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe F-1 Christie Box <br /> Domestic Well Onsite: ❑ Yes ❑No casing <br /> If yes, location and distance: height <br /> SAMPLING ABOVEGROUND <br /> Holding Temperature: COMPLETION CCO PtETION <br /> Method: Ground Surface' + <br /> Screening Method: ori <br /> Verified Chain of Custody: ❑ Yes El No —`--n' <br /> ft. <br /> tt. <br /> SPOILS <br /> k = d <br /> Contamination Noted: ❑ Yes ❑No =' <br /> If yes,spoils storage Location: e►oned <br /> eet�on — <br /> Covered: ❑ Yes ❑No <br /> If yes, material: (� <br /> GROUTING or DESTRUCTION Total Depth: ® =_ <br /> Depth to Water: O A-. n' ft. <br /> Grout Material: Kpak ft� a�_ <br /> MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: TA (')F At Casing Type: <br /> C- wn 6'arve-1+x <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation ($Boring Destruction Bags iz Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> ❑ Gravity gTremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> allons Bas gallons Bags <br /> Thickest Thinnest RBags Thickest Thinnest ttBags Bentonite/Cement Mix 3% Mix 5%Mix <br /> eT-5:;) s 1 s to 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 15 3 15 30 3 <br /> 10 20 4 20 40 4 <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 B 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 />