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S A N J 0 A Q U I N Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here- <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: /iJ Inspector: Gt ll CONSTRUCTION <br /> Facility Address: ✓l <br /> Well Address: Total Depth: <br /> WP# N L4 N 6.1 Well#: Drilling Rig Type: <br /> Soil Boring#: <br /> Min 2"Annular EHD Seal Verified: ❑Yes ❑No <br /> Drilling Company: f („ <br /> Driller Onsite: Screen Length From: To: <br /> / Filter Pack From: To: <br /> d <br /> Consultant: n Bentonite From: To: <br /> Geologist: �i - 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 ABOVE-GROUND CHq�ygox <br /> Holding Temperature: COMPLETION COMPLETION <br /> Method: Ground s°roc. -- <br /> Screening Method: gfrout <br /> Verified Chain of Custody: ❑Yes ❑No <br /> tt. <br /> SPOILS <br /> Contamination Noted: ❑Yes ❑No _ <br /> If yes,spoils storage Location: ,b <br /> sacion ;"i <br /> Covered: ❑Yes ❑No = graYq pack <br /> If yes, material: <br /> t I � x .c <br /> GROUTING.or DESTRUCTION Total Depth:-.�-D-.40 toI�S tt <br /> Depth to Water: r 1 f <br /> Grout Material: MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation ADoring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> Gravity ❑Tres ' � ❑Other: Type of Method: <br /> Water C ent 471b Water Cement941b <br /> all Ba allons Bags <br /> Thickest Thinnest s Thickest Thinnest 118aBs BentonitelCement Mix 3% Mix 5°/a Mix <br /> 2,5 5 1 5 to 1 Bentonite per 47 Ib 1.41 2.47 <br /> 5 10 2 to 20 z Bentonite per 94 lb 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 7 35 70 7 <br /> 20 40 8 1 40 130 B <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.s*cehd.com <br />