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"—COUNTY— <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 'L Inspector: CONSTRUCTION <br />Facility Address: �°�`��\ �y�5 C"C a-0 . <br />Well Address: �� Total Depth: <br />WP# WQ e 'i Well#: P/a Drilling Rig Type: <br />Soil Boring#: (_ "( �. �`p %I - Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br />Drilling Company: <br />Driller Onsite: K����`'� Screen Length From: To: <br />(1o>►,a� <br />Filter Pack From: To: <br />Consultant: <br />Geologist: IN Bentonite From: To: <br />Public Water System Onsite: <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING N lIpl <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: <br />SPOILS r._Y* <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes <br />❑ Yes <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: CID r <br />Depth to Water: ✓� 3�l <br />Grout Material: ,,j L_ 4jtr <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />El Boring Installation /Boring Destruction <br />METHOD USED <br />El Pressure Grout ❑Over Drill <br />❑ Gravity �Tremie ❑Other: <br />Water <br />Cement 471b <br />Bas <br />Water <br />RaI11111 ons <br />Cement 94 lb <br />Bags <br />—gallons <br />Thickest Thinnest <br />#Bags <br />Thickest Thinnest <br />#Bags <br />2.5 <br />5 <br />10 <br />1 <br />5 <br />10 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />3 <br />10 <br />20 <br />4 <br />20 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />5 <br />15 <br />30 <br />6 <br />30 <br />E70 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />7 <br />20 <br />40 <br />8 <br />40 <br />8 <br />Grout From: To: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />casing <br />h,eight <br />ABOVE -GROUND c; sszY aox <br />G=nd SWac2 m <br />ptoui <br />t4. <br />t3. <br />slatted — _ _ <br />yw <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 />BentoniteXement Mix 3% Mix S% Mix <br />Bentonite per 47 Ib 1.411 2.47 <br />Bentonite per 94 Ib 2.821 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 />