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SA N t 1 0A0 U I V Environme, I Health Department —COUNTY— Grectness grows here. Monitoring Well/Soil Boring Inspection Report Date: Inspector: d k .+� CONSTRUCTION Facilit Add ess: kb Z-4- Well Address: Total Depth:s f WP# a005 -77) Well#: Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: d1yes ❑No Drilling Company: 6'.#16'' Driller Onsite: Screen Length From: To: P'l Consultant: Z Filter Pack From:, L,� To: !�rt — Geologist: Bentonite From: To:�' f /� Grout From: / To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Oh t_ Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: height W- T SAMPLING ABOVE-GROUND CNR15T1'804 Holding Temperature: CowLET10N conaP=oN Method: Cmr)d Suiacs Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No ft. ft. SPOILS ft. Contamination Noted: ❑ Yes ❑No — m If yes,spoils storage Location: siottQd sac.on Covered: ❑ Yes ❑No 9�m Pack If yes, material: �tx GROUTING or DESTRUCTION Total De I ghr��® .. Depth to Water: Grout Material: Gallo�ts of Grout Used: MATERIALS/DEVELOPMENT Casing Type: i /ell Installation ❑Well.Destruction Blank Feet Screen Feet ❑Boring Installation ❑ Slot Size: Boring Destruction Bags Size: Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity ❑Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bags Rall ons Bags Thickest Thinnest 9Bags Thickest Thinnest #Bags Benton itefCement Mix 3% Mix 3%Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 s 10 2 10 20 2 7.5 15 3 15 30 3 Bentonite per 94 Ib 2.82 4.7 i 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 1 60 6 17.5 35 7 35 1 70 7 20 40 8 40 1 80 8 10/16/2017 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1, www.sicehd.com