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SANJOAQUIN <br />—COUNTY <br />�v!eu(����ss gr,>•,tis <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: I Z Z Inspector: CONSTRUCTION <br />Facility Address: 1 Well Address: Total Depth: <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#: <br />Min 2" Annular EHD Seal Verified: <br />Drilling Company:DrAit <br />❑ Yes []No <br />Driller Onsite: 1j jScreen <br />Length <br />From: <br />To: <br />Consultant: — <br />ju)e5 Filter Pack <br />J <br />From: <br />To: <br />Geologist: <br />Bentonite <br />From: <br />To: <br />5 <br />Grout <br />From: <br />To: <br />Public Water System Onsite: <br />❑ Yes El No COMPLETION <br />❑ Stove Pipe <br />❑Christie Box <br />Domestic Well Onsite: ❑ Yes 1:1 No <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 />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: I I <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: 1, 3 <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation P.Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />Gravity ❑Tremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />BBags <br />Thickest Thinnest <br />ryBags <br />2.5 <br />5 <br />1 1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 1 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 <br />8 <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.s*cehd.com <br />