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SAN FAQ U N Environmental Health Department <br /> COUNTY -- <br /> Greatness grows here . <br /> Monitoring Well / Soil Boring Inspection Report <br /> Date , 7i� Inspector : CONSTRUCTION <br /> Facility A dress : ` ' e �w-� P.A� <br /> Well Address : Total Depth : <br /> WP # (� Well : l Drilling Rig Type . <br /> Soil Boring# : Min 2 " Annular EHD Seal Verified : ❑ Yes [] No <br /> Drilling Company : <br /> Driller Onsite : �� J Screen Length From : To : <br /> Consultant : Filter Pack From : To : <br /> Geologist : Bentonite From : To : <br /> Grout From : To : <br /> Public Water System Onsite : ❑ Yes ❑ No COMPLETION ❑ Stove Pipe ❑ Christie Box <br /> Domestic Well Onsite : ❑ Yes ❑ No casing <br /> If yes , location and distance : height <br /> SAMPLING ABOVEGROUND CHRLM1 Sox <br /> Holding Temperature : COWLETION COMPLETION <br /> Method . °j°t"'� S`�r"' ""+'""` <br /> Screening Method : grout <br /> Verified Chain of Custody : ❑ Yes ❑ No ft• <br /> ft. <br /> ft. loom loodoomme <br /> SPOILS :Kmommommom <br /> ti __ <br /> Ad <br /> doommammm <br /> Contamination Noted : ❑ Yes ❑ No ` _ ID <br /> a <br /> If yes , spoils storage Location : _ <br /> stoned � r <br /> Covered : El Yes <br /> Yes ❑ No — <br /> :� : — gra,ret pack <br /> If yes , material : <br /> GROUTING or DESTRUCTION Total Depth : <br /> . ixoj <br /> Depth to Water : n• ft• <br /> Grout Material . <br /> Gallons of Grout Used : MATERIALS / DEVELOPMENT <br /> Casing Type : <br /> ❑ Well Installation ' 9.Well Destruction V4 11 Blank Feet Screen Feet <br /> 1( WV <br /> Slot Size : <br /> ❑ Boring Installation ❑ Boring Destruction Bags of Cement : <br /> METHOD USED ¢ _��n� Bags Sand / Gravel : <br /> Y� <br /> Type/ Brand of Bentonite : <br /> F] Pressure GroWTremie <br /> ver Drill Filter Pack Type/Size : <br /> El Gravity ❑ Other : Type of Method : <br /> Water Cement 471b Water Cement 941b <br /> allons Bas Rallons Bags <br /> Thickest Thinnest # Bags Thickest Thinnest # Bags Bentonite/Gement Mix 3 % MIX S % MIX <br /> 2 . 5 s 1 V 5 10 1 Bentonite per 47 Ib 1 .41 2 .47 <br /> s 10 z V 10 zo z Bentonite per 94 Ib 2082 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 7 35 70 7 <br /> 20 40 s177740 80 s <br /> 10/ 16/ 2017 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 1 F 209 464- 0138 www . s ' cehd . com <br />