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SAN..-.10AQUIN <br />Environmental Health Department <br />—COUNTY— <br />Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 'L31 -°v` Inspector CONSTRUCTION <br />Facility Address: <br />Well Address: <br />WP# Well#: <br />Soil Boring#: �' j�d T \'3T ?�D N\ <br />Drilling Company: <br />Driller Onsite: <br />Consultant: <br />Geologist: P' <br />Public Water System Onsite: ❑ Yes ufNo <br />Domestic Well Onsite: ❑ Yes L/1No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑No <br />SPOILS <br />Contamination Noted: ❑ Yes A0 <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ZNo <br />If yes, material: <br />i <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: NA. ' %' <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />jGravity ❑Tremie ❑Other: <br />Water <br />gallons <br />From: <br />Cement 471b <br />Bas <br />Water <br />gallons <br />From: <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />Bags <br />Thickest Thinnest <br />#Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.53 <br />35 <br />70 <br />7 <br />20 <br />0 <br />8 <br />40 <br />80 <br />8 <br />Total Depth: _ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑ Yes [I No <br />Screen Length <br />From: <br />To: <br />Filter Pack <br />From: <br />To: <br />Bentonite <br />From: <br />To: <br />Grout <br />From: <br />To: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />8. <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />Screen Feet <br />Benton itefCement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sicehd.com <br />