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SANc10AQUIN <br /> Environmental Health Department <br /> 1 COUNTY— <br /> ,Fq<Fo? P°/ Greatness grows here. <br /> U Monitoring Well/Soil Boring Inspection Report <br /> Date: [ 2q-0InspV,?L <br /> ' �/� A CONSTRUCTION <br /> Facility Address: a <br /> Well Address: 'S. C (.h Total Depth: <br /> WP# s Well#: Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: b N Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br /> Driller Onsite: � t Screen Length From: To: <br /> Consultant:(..iVt Filter Pack From: To: <br /> Geologist: Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes ❑No casing <br /> If yes, location and distance: W 1 height <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: COt"��ION COMP FnON <br /> Method: Ground Surface <br /> Screening Method: gro(a <br /> Verified Chain of Custody: ❑ Yes El No <br /> ft. <br /> ft. <br /> SPOILS y: <br /> = m <br /> Contamination Noted: ❑ Yes El No = <br /> If yes,spoils storage Location: afonad <br /> on <br /> Covered: ❑ Yes El No <br /> 9-VW Pack <br /> If yes, material: s <br /> GROUTING or DESTRUCTION Total Depth: as —T <br /> Depth to Water: <br /> -ft. — n. <br /> Grout Material: <br /> MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: 3 Casing Type: <br /> ❑Well Installation ell Destruction Blank Feet Screen Feet <br /> �Iw Slot Size: <br /> ❑Boring Installation ❑Boring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> El Pressure Grout% Over Drill Filter Pack Type/Size: <br /> ❑ Gravity *remie K00ther: Type of Method: <br /> Water Cemen 471b Water Cement 941b <br /> allons Ba allons Bags <br /> Thickest Thinnest 9Bags Thickest Thinnest bBags Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94 lb 2.82 4.7 <br /> 7.5 IS 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 /> Li 1004S <br /> 1868 E. H zelton Avenue Skton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.secehd.com <br />