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SAN_JOAQUIN Environmental Health Department <br /> --COUNTY— <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> r .O <br /> Dater" Inspector: +� CONSTRUCTION <br /> Facility Address: p�/ <br /> Well Address: Total Depth: <br /> WP# Q Well#: AO - l0 Drilling Rig Type: CJ <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ONO <br /> Drilling Company: Screen Length From: To: <br /> Driller Onsite: Filter Pack From: To <br /> Consultant: `�" Bentonite From: To: <br /> Geologist: 0 Grout From: To: <br /> Public Water System Onsite: ❑Yes ONO COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑Yes ONO casing <br /> ..� height <br /> If yes,location and distance: <br /> SAMPLING ABOVE-GnO11ND cHimimW-BOX <br /> COMPLETION COMPLEnON <br /> Holding Temperature: 03round svl=s <br /> Method: grout <br /> Screening Method: tt. <br /> Verified Chain of Custody: ❑ Yes ONO tt• <br /> SPOILS e <br /> Contamination Noted: ❑Yes ❑No . <br /> If yes,spoils storage Location:� .tatted <br /> sec4on <br /> Covered: ❑Yes ONO = aR Pack <br /> if yes, material: I 1 <br /> GROUTING or DESTRUCTION Total De t :�� tt = tt. <br /> Depth to Water: ^ N <br /> Grout Material: MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: ti Casing Type: <br /> Blank Feet Screen Feet <br /> ❑Well Installation Well Destruction Slot Size: <br /> ❑Boring Installation OBoring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure GroutAver Drill Filter Pack Type/Size: <br /> ❑ Gravity /�Tremie ❑Other: <br /> Type of Method: <br /> Water Came t471b Water Cement 941b <br /> aliens Ba s allons as s <br /> Thickest Thinnest pBag$ Thickest Thinnest #Bags Bentonite/Cement Mix 3%Mix 5% Ix <br /> Bentonite per 47 Ib 1.41 2.47 <br /> 2.5 5 1 5 10 1 2.82 4.7 <br /> 5 10 2 10 20 1 Bentonite per 941b <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 a 1 40 11 e0 B 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 IF209 464-0138 1 www sicehd.com <br />