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SAN]OAQUIN <br />COUNTY— <br />Environmental Health Department <br />¢ - Greatnt�,s <br />j:o:Ys hese. <br />Cement 471b <br />Bas <br />Water <br />Rallons <br />Monitoring <br />Well/Soil Boring Inspection Report <br />✓(Z N ZZ <br />v, <br />q Bags <br />Date: <br />I]spector: <br />1 <br />CONSTRUCTION <br />Facility Address: <br />r✓�V <br />5 <br />„ice' <br />WellAddres : <br />10 <br />20 <br />Total Depth: <br />WP# <br />15 <br />Well#: <br />Drilling Rig Type: <br />Soil Boring#: <br />F —ZZ <br />-oW <br />20 <br />Drilling Company: <br />Ve <br />40 <br />Min 2" Annular EHD Seal Verified: ❑ Yes 11 No <br />Driller Onsite: <br />/QL—fX <br />I <br />Screen Length From: To: <br />Consultant:Filter <br />5 <br />15 <br />Pack From: To: <br />Geologist: <br />30 <br />60 <br />Bentonite From: To: <br />17.5 <br />35 <br />7 <br />Grout From: To: <br />Public Water System Onsite: <br />❑ Yes <br />11 No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: ❑ Yes El No <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes El No <br />cpnn r, <br />Contamination Noted: ❑ Yes El No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCT ON Total Depth: D S <br />Depth to Water: <br />Grout Material: e!n 'n <br />Gallons of Grout Used: ,r <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity >6emie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />Rallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />A Bags <br />Thickest Thinnest <br />q Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <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 />MATE RIALS/DEVELOP ME NT <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.s4cehd.com <br />