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%s ,i.7 Q U I N Environmental Health Department <br />' `)—COUNTY— <br />Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: `CUVIL"1 IX Inspector: <br />Facility Address: <br />❑ Yes <br />Well Address: <br />1 <br />WP# `1'L% <br />G3 Well#: <br />Soil Boring#: j,- <br />Z <br />Drilling Company: <br />Method: <br />Driller Onsite: <br />1 <br />Consultant: <br />Geologist: <br />10 20 <br />Public Water System Onsite: 0 Yes ❑No <br />Domestic Well Onsite: <br />If yes, location and distance: <br />❑ Yes <br />I�'JNo <br />SAMPLING <br />Thickest Thinnest <br />ttBags <br />Holding Temperature: <br />#Bags <br />2.5 5 <br />Method: <br />5 10 <br />1 <br />Screening Method: <br />2 <br />10 20 <br />Verified Chain of Custody: <br />❑ Yes <br />❑No <br />SPOILS <br />3 <br />10 20 <br />Contamination Noted: <br />❑ Yes <br />❑No <br />If yes, spoils storage Location: <br />5 <br />25 50 <br />Covered: <br />❑ Yes <br />❑No <br />If yes, material: <br />6 <br />17.5 35 <br />GROUTING or DESTRUCTION Total Depth: (go <br />Depth to Water: 1 <br />Grout Material: N,4 l <NNLNN- <br />Gallons of Grout Used: t:� 71` <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation 013oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity iTremie ❑Other: <br />Water <br />gallons <br />Cement 47 lb <br />Bas <br />Water <br />gaill ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />ttBags <br />Thickest Thinnest <br />#Bags <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 />35 70 <br />7 <br />20 <br />40 8o <br />S <br />CONSTRUCTION <br />Total Depth: _ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑ Yes El No <br />Screen Length <br />From: <br />To: <br />Filter Pack <br />From: <br />To: <br />Bentonite <br />From: <br />To: <br />Grout <br />From: <br />To: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />ABOVE -GROUND CHFi3S7Y 30x <br />COWLEriON COMPLETiCN <br />Gnaund SwixY <br />grout <br />ff. <br />—_ <br />- w <br />— o <br />slotted - <br />g > w pack <br />#t. =IFtt. <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 />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.slcehd.com <br />