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SAN;JOAQUIN IiJ —COUNTY Greatness grows here. Environmental Health Department Monitoring Well/Soil Boring Inspection Reporl Public Water System Onsite Domestic Well Onsite: If yes, location and distance: SAMPLING Holding Temperature: Method: Screening Method: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑ Yes ❑No Verified Chain of Custody: ❑ Yes ❑No SPOILS Contamination Noted: ❑ Yes ❑No If yes, spoils storage Location: Covered: ❑ Yes El No If yes, material: GROUTING or DESTRUCTION Total Depth:_ Depth to Water: Grout Material: PIA - Gallons of Grout Used: ❑Well Installation ❑Well Destruction ❑Boring Installation ;Aloring Destruction METHOD USED *ressure Grout []Over Drill ❑ Gravity ❑Tremie ❑Other: ❑ Yes ❑ No To: To: To: To: ❑Christie Box ,51P 1ATERIA qiYtasing Type: Blank Feet Slot Size: Bags of Cement: Bags Sand/Gravel: Type/Brand of Bentonite: Filter Pack Type/Size: Type of Method: Water gallons C ent 4 7 1 b Bas Date: �2 Inspector:�l CONSTRUCTION Cement 94 lb Bags Facility Ad res : \ ` K Thickest Thinnest NBags Well Address: Total Depth: 1 WP# Well#: Drilling Rig Type: 1 Soil Boring#: 10 2 10 Min 2" Annular EHD Seal Verified: Drilling Compal 15 3 Driller Onsite: Screen Length From: Consultant: A uc —T—uh I Filter Pack From: Geologist: Bentonite From: 12.5 Grout From: Public Water System Onsite Domestic Well Onsite: If yes, location and distance: SAMPLING Holding Temperature: Method: Screening Method: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑ Yes ❑No Verified Chain of Custody: ❑ Yes ❑No SPOILS Contamination Noted: ❑ Yes ❑No If yes, spoils storage Location: Covered: ❑ Yes El No If yes, material: GROUTING or DESTRUCTION Total Depth:_ Depth to Water: Grout Material: PIA - Gallons of Grout Used: ❑Well Installation ❑Well Destruction ❑Boring Installation ;Aloring Destruction METHOD USED *ressure Grout []Over Drill ❑ Gravity ❑Tremie ❑Other: ❑ Yes ❑ No To: To: To: To: ❑Christie Box ,51P 1ATERIA qiYtasing Type: Blank Feet Slot Size: Bags of Cement: Bags Sand/Gravel: Type/Brand of Bentonite: Filter Pack Type/Size: Type of Method: Water gallons C ent 4 7 1 b Bas Water gall ons Cement 94 lb Bags Thickest Thinnest '--x8ags Thickest Thinnest NBags 2.5 5 1 5 10 1 5 10 2 10 20 2 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 ft. Screen Feet Bentonite/Cement Mix 3% Mix 5% Mix Bentonite per 47 Ib 1.41 2.47 Bentonite per 94 Ib 2.82 4.7 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.socehd.com