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SAN:JOAQUIN Environmental Health Department <br /> -- COUNTY— <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date:1. 5��L��-�tfispector: CONSTRUCTION N((, <br /> Facility Address:']1�o 0C^-—�A­-1 <br /> Well Address: A ;/A Total Depth: <br /> WP# Well#: A-)/�) Drilling Rig Type: <br /> Soil Boring#: Z F Min 2" Annular EHD Seal Verified: ❑ Yes []No <br /> Drilling Company: [n 'Q.,�t,.� <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: Filter Pack From: To: <br /> Geologist:____ bentonite Fro1n: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes ONo COMPLETION ❑ Stove Pipe []Christie Box <br /> Domestic Well Onsite: ❑ Yes /No —IT <br /> casingIf yes, location and distance: Iheight <br /> SAMPLING AsovE-GACUNo <br /> COWLETION COMPLY-50X <br /> Holding Temperature: contPtEncN <br /> Method: CcwrdSmacs <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes ❑No �ft' <br /> tt. <br /> ft. <br /> SPOILS <br /> Contamination Noted: ❑ Yes ❑No <br /> If yes, spoils storage Location: .brad <br /> Covered: ❑ Yes ❑Nci <br /> If yes, material: e <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: <br /> Grout Material: Nf%Az c Er^�n <br /> Gallons of Grout Used: - (� cAa MATERIALS/DEVELOPMENT /V <br /> ' Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: _ <br /> ❑Boring Installation C Boring Destruction Bags iz Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> C Gravity �1Trernie ❑Other: Type of Method: <br /> Water /Cement 471b Water Cement 941b <br /> gallons Bags gallons Bags <br /> Thickest Thinnest Bags Thickest Thinnest "Bags Bentonite/Cement Mix 3% MIX 3% Mix <br /> 2.5 (5D 5 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> 5 10 10 20 2 Bentonite per 94 Ib 2.82 4.7 <br /> 7.5 15 3 15 30 3 <br /> i0 20 4 20 40 4 <br /> 12.5 25 5 1 25 50 1 5 <br /> 15 30 6 30 60 6 <br /> 17.5 35 I - 35 70 7 <br /> 20 40 8 1 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 www.sicehd.com <br />