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�. �F SAW,,J0AQUIN <br />J: <br />' —COUNTY— <br /><<;�=`: ` G,-ectness grows here, <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: © Inspector: CONSTRUCTION <br />Facility Address:. toa-'y <br />Well Address: Total Depth: <br />WP# (i Ls{ 'Z J., y4 Well#:NC Drilling Rig Type: <br />Soil Boring#: S.,' k--� - Min 2" Annular EHD Seal Verified: <br />Drilling Company: 'C"'F- <br />❑ Yes ❑No <br />Driller Onsite: Screen Length From: To: <br />Consultant: "C,� <br />Filter Pack From: To: <br />Geologist: Bentonite From: To: <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 <br />❑ Yes <br />❑ Yes ❑No <br />❑ Yes I N0 <br />If yes, spoils storage Location: <br />Covered: ❑ Yes /No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: -CS <br />Depth to Water: 'gyp <br />Grout Material: <br />Gallons of Grout Used: '� q <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 />gallons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />9Bags <br />Thickest Thinnest <br />4Bags <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 />15 <br />30 <br />3 <br />10 <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 />8 <br />40 <br />80 <br />8 <br />Grout From: To: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />ABOVE -GROUND CHRZrr-sox <br />COWLET)ON COMPLETION <br />G=ncl 5wiacs <br />grout <br />ft. <br />it. <br />ft. _ <br />— o <br />• <br />— o <br />slattQd - <br />sac5orn <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 />BentonitefCement 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 />