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SAKJOAQUIN Environmental Health Department —COUNTY— `; Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date:'L1-0)t '%IIONN Spector: CONSTRUCTION Facility Address: Well Address: Total Depth: WP# Well#: Drilling Rig Type: Soil Boring#: 'nom�.� �rT�`� 4S Min 2"Annular EHD Seal Verified: ❑ Yes El No Drilling Company:_�`J�� Driller Onsite: ' s� :%.- _ Screen Length From: To: VJ Filter Pack From: To: Consultant: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes �No casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: co&FLErj0N CcaWLETiON Method: G=rjdSorts + Screening Method: grotA Verified Chain of Custody: ❑ Yes ❑No ft' ft. ts. SPOILS < Contamination Noted: ❑ Yes ❑No :` If yes,spoils storage Location: sse�on t Covered: ❑ Yes El No = — yrz,r.t pack If yes, material: `S GROUTING or DESTRUCTIONTotal Depth:�c , `S s =_ Depth to Water: Grout Material: �1 Gallons of Grout Used: MATERIALS/DEVELOPMENT Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation ( Boring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity ❑Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bas gallons Bags Thickest Thinnest ttBags Thickest Thinnest #Bags BentoniteXement Mix 3% Mix 3% MIX 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 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 5 35 70 7 2D 4 8 40 80 0 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sicehd.com