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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 2 2 Inspector: <br />Facility A dre s: 5 <br />Well Address: <br />WP# Well#: <br />Soil Boring#: <br />Drilling Company: cae') Fig <br />Driller Onsite: <br />Consultant: <br />Geologist: <br />CONSTRUCTION <br />Total Depth: _ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />From <br />Filter Pack <br />From <br />Bentonite <br />From <br />Grout <br />From <br />Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe <br />Domestic Well Onsite: ❑ Yes ❑No <br />If yes, location and distance: <br />cnnnvl lnlr <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody <br />SPOILS <br />Contamination Noted <br />If yes, spoils storage Location: <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Covered: ❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material <br />❑ Yes ❑ No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />casing <br />height <br />ABOVE -GROUND CHR S7Y48Ox <br />COMPLETION COMPLETION <br />Ground Surface <br />grout <br />tt. <br />tt. <br />_ <br />_ a <br />abttad = � <br />tion <br />gravwi Pack <br />MATERIALS/DEVELOPMENT <br />Gallons of Grout Used: pt <br />Casing Type: <br />❑Well Installation ❑Well Destruction Blank Feet <br />Slot Size: <br />❑Boring Installation�Boring Destruction <br />✓✓ Bags of Cement: <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity.Tremie ❑Other <br />tmow_ <br />Bags Sand/Gravel: <br />� Type/Brand of Bentonite: <br />�( �-� �( Filter Pack Type/Size: <br />Type of Method: <br />Water <br />allons <br />9Kent4711b <br />C <br />Water <br />igall ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />b Bags <br />Thickest Thinnest <br />tlBags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 10 <br />2 <br />10 20 <br />2 <br />7.5 15 <br />3 <br />15 30 <br />3 <br />10 20 <br />4 <br />20 40 <br />4 <br />12.5 25 <br />5 <br />25 50 <br />5 <br />15 30 <br />6 <br />30 60 <br />6 <br />17.5 35 <br />7 <br />35 70 <br />7 <br />20 40 <br />8 <br />40 80 <br />8 <br />Screen Feet <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.411 2.47 <br />Bentonite per 94 Ib 2.821 4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue 1 Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.s*cehd.com <br />