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- `' SAN � FAQ � � N J En ironmental Health Department <br />� �� `° �� ----COUNTY--__ _ �w � O � a � � � U -� � ! � � 9 , ��U � .f <br />+�`�'�cr�oar��' Greatness graves her- . �,,,_,__� <br />Monitoring Well/Soil Boring Inspection Report j`'�Ui�e <br />Date: �UI( Z�� Inspector: ��vl. � Lrvt <br />Facility Address: �' Vl � <br />Well Addrells�: <br />WP# �JC�`i � • Well#: <br />Soil Boring#: <br />Drilling Company: 1��j' <br />Driller Onsite: <br />Consultant: �'U ~ �-�-�L- <br />Geologist: t;'J'1 <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 />❑ Yes ❑ No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: '�,a'���-� C� �/`� <br />Gallons of Grout Used: � f) �ZU �� <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation ❑Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ❑Tremie ❑Other: <br />�� r <br />+plater <br />gallons <br />Cer7ient 471b <br />Baas <br />5% Mix <br />+;Vata_r <br />allons <br />Cernent 941b <br />Ba s <br />Thickest <br />Thinnest <br />�Eiags <br />4.7 <br />T}��ickest <br />Thinnest <br />ttBags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />s <br />10 <br />2 <br />10 <br />20 <br />2 <br />15 <br />30 <br />3 <br />7.5 <br />15 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />25 <br />50 <br />5 <br />12,5 <br />25 <br />5 <br />30 <br />EO <br />6 <br />15 <br />30 <br />6 <br />35 <br />70 <br />7 <br />17.5 <br />35 <br />7 <br />40 <br />80 <br />8 <br />20 <br />4U <br />8 <br />CONSTRUCTION <br />>--.� <br />Total Depth: __ <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑Yes ❑No <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout From: To: <br />COMPLETION <br />❑ Stove Pipe ❑Christie Box <br />�~ -GROUND <br />casing <br />height <br />�sovE c+�sssrY-aox <br />COM?L..ET10N COMPLETION <br />C�ocand Swia�ca <br />procrt <br />�t. <br />ft. <br />ft. <br />iY� <br />v' �� p <br />.> w Q <br />m <br />__ o <br />s la tc8d :: � <br />scion _ <br />:�- = .� <br />�nvd pxk <br />�. <br />:;. _ <br />�n. � n. <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 Pacl< Type/Size: <br />Type of Method: <br />Screen <br />Feet <br />BentonitelOement Mix <br />3% Mix <br />5% Mix <br />Bentonite per 4T Ib <br />1.41 <br />2.47 <br />Bentonite per 94 Ib <br />2.82 <br />4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sicehd.com <br />