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,f S A NUJ OA U I N Q Environmental Health Department —.COUNTY-- Greotness grows here. Monitoring Well/Soil Boring Inspection Report Date:—��Inspector: CONSTRUCTION Facility Address: Well Address: N-� t-NS PcQ:ft�.� Total Depth: yti N%3 Well#:-4,,Q/tk- Drilling Rig Type: Soil Boring#: "i- g I p Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company:y-4 be t_hP.aT r'-->'-�i!0(--*SjV blJ Screen Length From: To: Driller Onsite: Consultant: Fi er,Pack From: To: Ben o Geologist: -�p�T,.�-c�G� n tie From: To: Grout From: To: Public Water System Onsite: ❑ Yes No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: J Yes ❑No casing If yes, location and distance: height SAMPLING IJ I ABOVE-GROUND Holding Temperature: COi4'3''LETi°N OpoN Method: G=d Surlacs Screening Method: Grout Verified Chain of Custody: ❑ Yes ❑Nott. ft. ft. SPOILS <�= Contamination Noted: ❑ Yes P/N o ` _ If yes, spoils storage Location: sbnod y stiction Covered: [] Yes TNo _ .�: — gra,ra par3c If yes, material: GROUTING or DESTRUCTION Total Depth:XONS AD t 'LOQ 1� 1 \�� I\b, Depth to Water:IJ IN % ft' Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: -1 S d� Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: El Boring Installation /Boring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑1Pressure Grout ❑Over Drill Filter Pack Type/Size: J/J Gravity ❑Tremie ❑Other: Type of Method: / Water Cement 471b Water Cement 941b gallons Bas ealill ons Bags Thickest Thinnest pBags Thickest Thinnest #Bags Bentonite/Cement Mix 3% Mix 5% Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 5 Mz 10 20 2 Bentonite per 94 lb 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 www.sicehd.com