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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> �- <br /> Greatness grouts her , . f� • 2 � �„ti <br /> Monitoring Well / Soil Boring Inspection Report <br /> Date : .3 ' 2 �y/ Inspector : Af�x� CONSTRUCTION <br /> Facility Address : i!f&9Te tVP AO&drw cd <br /> Well Address , Total Depth : <br /> WP # 06) S// d Well # : Drilling Rig Type : <br /> Soil Boring# : QWP �/ 7 Min 2 " Annular EHD Seal Verified : ❑ Yes ❑ No <br /> Drilling Company : �Qd G <br /> Driller Onsite : -x dy- Screen Length From : To : <br /> �+�� }%•vim 6•- Filter Pack From : To : <br /> Consultant : 2 <br /> - � Bentonite From : To : <br /> Geologist : l4d <br /> Grout From , To : <br /> Public Water System Onsite : ❑ Yes El No COMPLETION ❑ Stove Pipe ❑ Christie Box <br /> Domestic Well Onsite : ❑ Yes El No casing <br /> If yes , location and distance : height <br /> 7F r <br /> SAMPLING �yg.GaOUNp cHFItsTY-Box <br /> Holding Temperature : COMPLETION COMPLETION <br /> Method : G= nd Sudacs <br /> Screening Method , grocrt <br /> Verified Chain of Custody : ❑ Yes El No NNEUND ft - <br /> ft. <br /> ft . <br /> SPOILS <br /> Contamination Noted : ❑ Yes El No = <br /> If yes , spoils storage Location : <br /> stoned y . — <br /> &*Clon <br /> Covered : ❑ Yes ❑ No <br /> VIV1w Pack <br /> If yes , material : 40010100111 <br /> _ <br /> r; <br /> GROUTING or DESTRUCTION Total Depth : � SIF� <br /> Depth to Water : <br /> Grout Material : / if-y >� IiYwY MATERIALS / DEVELOPMENT <br /> Gallons of Grout Used : 2 ' � 'er�y'// - Casing Type : <br /> ❑ Well Installation ❑ Well Destruction Blank Feet Screen Feet <br /> ❑ Boring Installation Slot Size : <br /> 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 /> ❑ Gravity ZTremie ❑ Other : Type of Method , <br /> Water Cement 471b Water Cement 941b <br /> gallons Bas gallons Bags <br /> Thickest Thinnest # Bags Thickest Thinnest Bags Bentonite/Cement Mix 3 % Mix 5 % Mix <br /> 2 . 5 5 1 5 10 1 Bentonite per 47 Ib 1 Al 2047 <br /> 5 10 2 10 20 2 Bentonite per 94 Ib 2 . 82 4 . 7 <br /> 7. 5 15 3 15 30 3 <br /> 10 20 4 20 40 4 <br /> 12 . 5 25 5 25 50 5 <br /> 15 30 6 30 60 6 <br /> 17. 5 35 1 7 35 70 7 <br /> 20 40 1 8 40 80 8 <br /> 10/ 16/ 2017 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 www . s * cehd . com <br />