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SAN JOAQUIN <br />—COUNTY - <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: ��-� 2`Z Inspector_ (ftV- <br />Facility Address: <br />Well Address: <br />WP# G D Well#: <br />Soil Boring#: - a <br />Drilling Company: <br />Driller Onsite: <br />Consultant: �Z <br />Geologist: <br />Public Water System Onsite <br />Domestic Well Onsite: <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑No <br />SPOILS <br />Contamination Noted: ❑ Yes 11 No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: z1�JJ <br />Depth to Water: -,- 3"% - <br />Grout Material: 4V teA <br />Gallons of Grout Used: A -1,5�G <br />❑Well Installation ❑Well Destruction <br />El Boring Installationring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity -?4remie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />water <br />eallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />J1 Bags <br />Thickest Thinnest <br />tlBags <br />2.5 s <br />1 <br />5 10 <br />1 <br />5 <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 />7 <br />35 70 <br />7 <br />20 40 <br />8 <br />40 80 <br />9 <br />CONSTRUCTION <br />Total Depth: _ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑ Yes ❑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 />ft. <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 />ft. <br />Screen Feet <br />Bentonite/Cement Mix 3% Mix 3% 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 />