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SANsd0A0UIN <br />.ern <br />Environmental Health Department <br />'." —COUNTY— <br />`;; Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: \�3 'L°1 " Inspector: CONSTRUCTION <br />Facility Address: 'L-`'�'�o Ps<;�Q�p%:�) <br />Well Address: Total Depth: <br />WP# Al-." OQ Well#: N/ rh Drilling Rig Type: <br />Soil Boring#: %'L, It— 3 <br />Min 2„ Annular EHD Seal Verified: El Yes ❑No <br />Drilling Company: Screen Length From: To: <br />Driller Onsite: v..J1t.. <br />Consultant: C— Filter Pack From: To: <br />Geologist: Bentonite From: To: <br />Grout From: To: <br />Public Water System Onsite: 0 Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes VIN <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 />GROUTING or DESTRUCTION ToV Depth:2_��O I SD <br />Depth to Water: <br />Grout Material:A't <br />Gallons of Grout Used: `15 <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation C Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity )Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />I <br />Water <br />Rallons <br />Cement 941b <br />BaRs <br />Thickest Thinnest <br />kBags <br />Thickest Thinnest <br />#Bags <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 <br />5 <br />25 <br />50 <br />5 <br />1s 3 <br />0 <br />30 <br />60 <br />6 <br />17.5 1 <br />7 <br />35 <br />70 <br />7 <br />20 1 40 <br />8 <br />40 <br />80 <br />8 <br />casing <br />height <br />ABOVE -GROUND CHRZW-Box <br />COMPLEr N c mPLEncN <br />cra;nd Suiacs <br />grout <br />ft. <br />ft. <br />tt. <br />— o <br />1.c w <br />0 <br />stottad = <br />.. = g-wiW park <br />ft. <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 />ft. <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.sicehd.com <br />