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SAN<;•JOAQUINi Environmer._al Health Department <br /> —COUNTY— <br /> iFl? ° Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: 1 � Inspector: CONSTRUCTION <br /> Facility Address: Voo <br /> Well Address: Total Depth: <br /> WP# 'A %% ) Well#:M�1- Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑Yes []No <br /> Drilling Company: <br /> XILI� Screen Length From: To: <br /> Driller Onsite: C <br /> Filter Pack From: To: <br /> Consultant: pis <br /> ( F.V�FG Bentonite From: To: <br /> Geologist: <br /> Grout From: To: <br /> Public Water System Onsite: Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: 11 <br /> Yes VNo � casing <br /> If yes,location and distance: � height <br /> SAMPLING u�Ql ABOVEGROUND IT <br /> Holding Temperature: COAi+LETbN COMPLETION <br /> Method: Ground Suiaa 7 <br /> Screening Method: Grout <br /> Verified Chain of Custody: ❑ Yes ❑No <br /> ff. <br /> SPOILS _ <br /> Contamination Noted: ❑Yes \NO r <br /> — o <br /> If yes,spoils storage Location: 013 <br /> section f <br /> Covered: Yes []No = g-vW pack <br /> If yes, material: <br /> i — <br /> GROUTING or DESTRUCTION Total Depth: 5D - <br /> Depth to Water: 5 <br /> O k. — 1—ft. <br /> Grout Material: WA SLC C SL� MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: \ LL n,o,� <br /> Casing Type: <br /> ❑Well Installation Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> []Boring Installation ❑Boring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand <br /> []Pressuresure Grout Over Drill Bentonite: <br /> Filter Pack Type/Size: <br /> e/Size: <br /> ❑ Gravity Vremie ❑Other: Type of Method: <br /> Water Vv cement 471b Water Cement 941b <br /> M1O <br /> ns Bags <br /> ns Bags <br /> Thinnest aBags Thinnest Psags Bentonite/Cement MIX 3%MIX 5%MIX <br /> 5 1 10 1 Bentonite per 47 lb 1.4112.47 <br /> 10 2 20 2 Bentonite per 94lb 2,82 4.7 <br /> 15 3 30 3 <br /> 20 4 40 4 <br /> 50 5 <br /> 30 6 60 6 <br /> 35 7 70 740 0 a0 0 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />