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SAN 10AQUIN <br />Environmental Health Department <br />-COUNTY -- <br />"9c;F�ar,:P' Greatness grows here <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 7 Inspector: (sirrt.- fr& <br />Facility Address: <br />Well Address: <br />WP# v Well#: <br />Soil Boring#: �'(E I f <br />Drilling Company: � 3`7 C Z cv►� <br />Driller Onsite: <br />Consultant: 'n�c, Ul <br />Geologist: X12 <br />Public Water System Onsite <br />Domestic Well Onsite: <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 />Covered: <br />If yes, material: <br />CONSTRUCTION <br />Total Depth: ____ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length From <br />Filter Pack From <br />Bentonite From <br />Grout From <br />❑ Yes ;Ao COMPLETION ❑ Stove Pipe <br />❑ Yes <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />GROUTING or DESTRUCTION Total Depth:; <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: '^- J <br />❑Well Installation ❑Well Destruction <br />❑Boring Installatio5Z]Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity 121,Tremie ❑Other: <br />Water <br />gall s <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />4Bags <br />Thickest Thinnest <br />4Bags <br />2.5 <br />5 <br />1 <br />5 10 <br />1 <br />5 <br />1k <br />1 <br />10 20 <br />1 <br />7.5 <br />1 <br />3 <br />15 30 <br />3 <br />10 <br />10 <br />4 <br />20 40 <br />4 <br />12.5 <br />25 <br />5 <br />25 50 <br />5 <br />15 <br />30 <br />6 <br />30 60 <br />6 <br />17.5 <br />35 <br />7 <br />35 70 <br />7 <br />20 1 <br />40 <br />8 1 <br />40 80 <br />8 <br />❑ Yes ❑ No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />casing <br />height <br />ABOVE -GROUND CNR1S ry4= <br />COMPLETION COMPLETION <br />Ground Surtaca <br />grout <br />ft. <br />57. <br />ft. <br />ft. <br />alottad <br />sacson — <br />IF <br />_ = gnwt pads <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/Cement 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.sacehd.com <br />