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SAN JOAQUIN <br />z, <br />--COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Public Water System Onsite <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 />❑ Yes El No COMPLETION ❑ Stove Pipe <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑ No <br />If yes, material: <br />1 <br />GROUTING or DESTRUCTION Total Depth:_ <br />Depth to Water: 11 , <br />Grout Material: NeA <br />Gallons of Grout Used: (I CI QJ <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation $Boring Destruction <br />MFTWnn I mrn <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity 'E�Tremie ❑Other: <br />Water <br />allons <br />r <br />�' <br />Date: LQ Inspector: <br />D'7'/t� <br />CONSTRUCTION <br />Facility Address: <br />Thickest Thinnest <br />9Bags <br />Well Address: <br />1 <br />Total Depth: Zit Cf' <br />10 <br />WP# U O 2 <br />Well#: <br />Drilling Rig Type: (, <br />Soil Boring#: C <br />20 <br />Min 2" Annular EHD Seal Verified: <br />Drilling Company: <br />pyo <br />15 <br />Driller Onsite: LA-04il <br />3 <br />Screen Length From: <br />Consultant: T' <br />20 <br />Filter Pack From: <br />Geologist: rX9 61Bentonite <br />12.5 25 <br />From: <br />25 <br />50 <br />Grout From: <br />Public Water System Onsite <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 />❑ Yes El No COMPLETION ❑ Stove Pipe <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑ No <br />If yes, material: <br />1 <br />GROUTING or DESTRUCTION Total Depth:_ <br />Depth to Water: 11 , <br />Grout Material: NeA <br />Gallons of Grout Used: (I CI QJ <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation $Boring Destruction <br />MFTWnn I mrn <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity 'E�Tremie ❑Other: <br />Water <br />allons <br />Cemen 71b <br />B <br />Water <br />gall ons <br />Cement 941b <br />gags <br />Thickest Thinnest <br />tlBags <br />Thickest Thinnest <br />9Bags <br />2.5 5 <br />1 <br />5 <br />10 <br />1 <br />5 10 <br />2 <br />10 <br />20 <br />2 <br />7.5 15 <br />3 <br />15 <br />30 <br />3 <br />10 20 <br />4 <br />20 <br />40 <br />4 <br />12.5 25 <br />5 <br />25 <br />50 <br />5 <br />1s 30 <br />6 <br />30 <br />60 <br />6 <br />17.5 35 <br />7 <br />35 <br />70 <br />7 <br />20 40 <br />8 <br />40 <br />80 <br />8 <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <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/Gement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <br />1010 3 "S 10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.socehd.com <br />