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SAN.J O A Q U I N <br /> Environmental Health Department <br /> —COUNTY-- <br /> `<.r Gnzotne,s .9roas fere. <br /> ii nI� Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspector, CONSTRUCTION <br /> Facility Address: <br /> Well Address: [ - Total Depth: <br /> WP#_ DUAA Well#: Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No <br /> Drilling Company: c1 U 1Y1 <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: P(Lo'l Filter Pack From: To: <br /> Geologist: Bentonite From: To: <br /> Grout From: To:-- <br /> Public <br /> o: _Public Water System Onsite: ❑ Yes [I No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes El No casing <br /> If yes, location and distance: height <br /> SAMPLING AZovsGnoutao _ <br /> Holding Temperature: CO&g'LEC10N cHaLs-ryCOMPLETiON <br /> Method: c3rwnd Surface <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes ❑No <br /> fs. <br /> ft_ <br /> SPOILS <br /> Contamination Noted: El Yes El No <br /> If yes,spoils storage Location: slo <br /> r _ <br /> Covered: ❑ Yes ❑No <br /> — grawt pack <br /> If yes, material: — <br /> GROUTING or DESTRUCTION Total Depth: A\ <br /> Depth to Water: 115 C — n <br /> Grout Material: UO%k \ji' A\ <br /> Gallons of Grout Used: MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation Well Destruction Blank Feet Screen Feet <br /> El Boring Installation ❑ Slot Size: <br /> Boring Destruction Bags Size: <br /> Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity XTremie Type of Method: <br /> Water Cement 471b Water Cement 94 lb <br /> gallons Bas gallons Bags <br /> Thickest Thinnest 4 Bags Thickest Thinnest VBags Bentonite/Cernent Mix 3% Mix 5% Mix <br /> 25 s1 1 5 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 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 9 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />