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-` SAN 0 A 0 U I N <br /> Environmental Health Department <br /> —COUNTY— <br /> Gr-eutness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspector: t CONSTRUCTION <br /> Facility Address:_I— <br /> �4-1I' q-er / <br /> Well Address: h Total Depth:_I <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: 2 9) <br /> Min 2" Annular EHD Seal Verified: Yes El No <br /> Drilling Company: I LU <br /> Screen Length From: <br /> Driller Onsite: To: <br /> Consultant: Filter Pack From:�f To: S <br /> Geologist: ((/(7 T�( � ) Bentonite From: To:_r. <br /> Grout From: To: O <br /> Public Water System Onsite: ❑ Yes CNo COMPLETION ❑ Stove Pipe ristie Box <br /> Domestic Well Onsite: ❑ Yes N0 casing <br /> If yes, location and distance: height <br /> SAMPLING ABOVE-GROUND ' <br /> c <br /> Holding Temperature: CO&PLEMN coMor%t <br /> Method: Gm6nd Surlacs 'v <br /> Screening Method: grout <br /> /;pn <br /> Verified Chain of Custody: El Yes ❑No ft. L6 <br /> ft. 7'kn. t b� SA--* <br /> SPOILS _ 1 00-V <br /> Contamination Noted: ❑ Yes El No = r � <br /> If yes,spoils storage Location: abnod <br /> Ye. C <br /> Baton -„ <br /> Covered: ❑ Yes ❑No <br /> sem+ I> b f ^�wrc <br /> If yes, material: = r� <br /> 6 s� <br /> GROUTING or DESTRUCTION Total Depth:_ = : P�0,3 �, a r� <br /> S~ <br /> Depth to Water: n W n 6 <br /> Grout Material: <br /> Gallons of Grout Used: MATERIALS DEVELOPMENT,. <br /> Casing Type: 4- <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> ❑Boring Installation TABoring Destruction Slot Size: ' % <br /> ?, <br /> Bags of Cement. fl� <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity ❑Tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 94 lb <br /> gallons Bas gallons Ba s <br /> Thickest Thinnest #Bags Thickest Thinnest #Bags BentonitelCement MIX 3% MIX 5% MIX <br /> 2.5 5 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 8 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.sicehd.com <br />