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SANdOAQUIM Environmental Health Department '._•tit- COUNTY— ¢Llr Ci(POI n P55 9lOWS hPIP. Monitoring Well/Soil Boring Inspection Report 125) a-1 5•S Date: 2 8�g 2�� Inspector: SU1�r�l CONSTRUCTION s/— Facility Address: J W bJv k l �Ow ) Well Address: Total Depth: WP# Ob Well#: Drilling Rig Type: Soil Boring#: 5 -I . 12 112,1 Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Compan : uk ,1, Driller Onsite: t� Screen Length From: To: Consultant: AA&Yvtw Filter Pack From: To; Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes El No casing If yes, location and distance: � height SAMPLING ABOVEGROUND COMPLETION CY-BOX Holding Temperature: cOMPLoMPtEnoN Method: Grand Su laa Screening Method: Drool _{ Verified Chain of Custody: ❑ Yes ❑No SPOILS Contamination Noted: ❑ Yes El No If yes,spoils storage Location: Covered: ❑ Yes ❑No section _ 10 5 yraval Padstti 1 y S If yes, material: GROUTING or DESTRUCTION Total Depth: 3 i � Depth to Water: NQAf Ct 19 d tt• # 15, 5 Grout Material: — MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: Well Installation ❑Well Destruction Blank Feet Screen Feet ❑Boring Installation ❑Boring Destruction Slot Size; Bags of Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: It Gravity ❑Tremie ❑Other: Type of Method: Water cement 4711) Water Cement 941b allons Bags eallons Basis Thickest Thinnest u ags Thickest Thinnest 11 Bags _ Bentonite/Cement MIX 3%MIX 5%MIX_ 2s s 1 5 10 1 1 Bentonite per 47 lb 1 1.411 2.47 5 10 2 10 20 2 Bentonite per 94 lb 1 2.821 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 is 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com