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�"°c SANnJOAQUIN <br />—COUNTY- <br />c,P 1 Greotness grows here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Reporl <br />Date: Itis Inspector: CONSTRUCTION <br />Facility Address: <br />Well Address: Total Depth: <br />WP# 0t1 L� y 1 Well#: Drilling Rig Type: <br />Soil Boring#: ('-1147 Min 2" Annular EHD Seal Verified: <br />Drilling Company: �,���;'��1h[ <br />Driller Onsite: ;Pt"'A —7 Screen Length From: <br />Consultant: Filter Pack From: <br />Geologist: Bentonite From: <br />Grout From: <br />Public Water System Onsite: ❑ Yes 11 No COMPLETION ❑ Stove Pipe <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING <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 />Covered: <br />If yes, material: <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: 4 iAA COL"" , <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity XTremie ❑Other: <br />Water <br />allons <br />Cement 71 <br />Bas <br />Water <br />eallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br /># Bags <br />Thickest Thinnest <br />ltBags <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 />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />B <br />40 <br />80 <br />8 <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />casing <br />height <br />—CWT <br />ABOVE -GROUND CHRIM 43OX <br />COMPLETION ccmPLETION <br />Ground surrar:e <br />Grout <br />it. <br />n. <br />0 <br />= e <br />= a <br />BIC tted = B <br />tiection — <br />g-1 Pack <br />Tv <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 />Bentonite/Cement 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 209 468-3420 1 F 209 464-0138 1 www.s4cehd.com <br />