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SA N J OAQ U I N Environmental Health Department —COUNTY C9GtFOPy'�P VI"r'UttIP.SS t,'!"!):::� 111•"'. Monitoring Well/Soil Boring Inspection Report Date: Inspector: CONSTRUCTION Facility Address:Z' !4y g�, T(;�n.n Well Address: Total Depth: WP# nn -12 � �f Well#: Drilling Rig Type: Soil Boring#: �) -� Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: G eo Cr Driller Onsite: Screen Length From: To: Consultant: i'►,Fe- eY Filter Pack From: To: Geologist: A S R-e—F Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: height SAMPLING AWVE-GROUND Holding Temperature: COMPLETION CHRISTYCOMA FTioN Method: GrwndSuface +— Screening Method: Dr«n Verified Chain of Custody: ❑ Yes El No ��ft. ft. ft. SPOILS Contamination Noted: ❑ Yes El No 'F •N• If yes, spoils storage Location: abtted _ s�c5on = Covered: ❑ Yes ❑No Pack If yes, material: GROUTING or DESTRUCTION Total Depth: 35"' Depth to Water: 3c), 5-1 fL _ ft• Grout Material: C V-t22 1 MATERIALS/DEVELOPMENT Gallons of Grout Used of(, a r-0L--t— Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: El Boring Installation�oring Destruction Bags iz Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity )�Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bas gall ons Bags Thickest Thinnest 4Bags Thickest Thinnest QBags Bentonite/Cement Mix 3% MIX 5% Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 s 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 www.sicehd.com