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SAN JOAQUIN <br />-COUNTY <br />GrestrieSs groes here. <br />Date: G <br />Facility Address::iz <br />Well Address. <br />WP# <br />Soil Boring#: <br />Drilling Comr <br />Driller Onsite: <br />Consultant <br />Geologist: <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Inspector: <br />CONSTRUCTION <br />r' . _ f <br />Total Depth: 16) f I' 41 <br />Well#: Drilling Rig Type: <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 />VerlfleArk <br />SPOILS <br />❑ Yes <br />❑ Yes <br />❑No <br />❑No <br />ain of Custody: ❑Yes LJ NO <br />Contamination Noted: ❑Yes ❑ No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRU <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used. <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation oring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />Gravity <br />❑Tremie ❑Other: <br />i <br />Water <br />allons <br />Cement 471b <br />Bas <br />5°l° Mix <br />Water <br />allons <br />Cement 941b <br />Ba s <br />Thickest <br />Thinnest <br />#Bags <br />4.7 <br />Thickest <br />Thinnest <br />ltBags <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 />1'30 <br />u <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 40 <br />8 40 <br />80 <br />8 <br />Min 2" Annular EHD Seal Vered: ❑Yes ❑No <br />Screen Length From: To: <br />Filter Pack From: To: <br />Bentonite From: To: <br />Grout <br />COMPLETION <br />From: <br />❑ Stove Pipe <br />To: <br />❑Christie Box <br />\�. <br />.. - :. <br />C4DMPLETION <br />I wh, 1�,- - <br />slonad <br />&*cdon <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 <br />Feet <br />BentvnitefGement Mix <br />3% Mix <br />5°l° Mix <br />Bentonite per 4l Ib <br />1.41 <br />2.47 <br />Bentonite per 94 Ib <br />2.82 <br />4.7 <br />u <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 <br />Feet <br />BentvnitefGement Mix <br />3% Mix <br />5°l° Mix <br />Bentonite per 4l 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 I Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjcehd.com <br />