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SANJOAQUIN Environmemal Health Department <br /> �•'� COUNTY <br /> . _, Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> I /J <br /> Date:'l 0 Inspector: CONSTRUCTION <br /> Facility Address: <br /> Well Address: Yr d I Total Depth: <br /> WP# 00 12ITZ 0 ell <br /> - 03 Drilling Rig Type: <br /> Soil Boring#-. Min 2"Annular EHD Seal Verified: ❑ Yes ❑No <br /> Drilling Company: <br /> Driller Onsite: M 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 AeOVE-GROUND <br /> CowLErioN CRRIBTYTIO <br /> Holding Temperature: catPlEtioN <br /> Method: Gmnasalac. �- <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes El No -i--tt• <br /> tt. <br /> SPOILS <br /> i l Contamination Noted: ❑ Yes ❑No 7e = " <br /> If yes, spoils storage Location: glotkaa = s <br /> an <br /> Covered: ❑Yes ❑No a� = 8 <br /> If yes, material: c <br /> GROUTING or DESTRUCTION Total Depth:_ <br /> Depth to Water: <br /> Grout Material: /Ug�E� MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> ❑Well Installation y(Well Destruction Blank Feet Screen Feet <br /> ❑Boring Installation E]Boring Destruction Slot Size: <br /> Bags of Cement: <br /> METHOD USED �1 Bags Sand/Gravel: <br /> Type/Brand of <br /> ❑ Filter Pack Type/Size: <br /> Pressure Grout Over Drill Bentonite: <br /> ii"�� <br /> ❑ Gravity Aremie Bother: Type of Method: <br /> Water Cement 471b Water Cement 94lb <br /> allons Bags siallons Bags <br /> Thickest Thinnest #Bags Thickest Thinnest #Bag+ _ Bentonite/Cement Mix 3% MIX 5% MIX <br /> 2.5 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94lb 2.82 4.7 <br /> 7.5 15 3 15 30 3 <br /> 30 20 4 20 40 4 <br /> 12.5 25 5 25 50 5 <br /> 1s 30 6 30 60 6 <br /> 17.5 35 7 35 70 7 <br /> 20 40 8 40 80 8 <br /> 10/16/2017 <br /> \ Z in <br /> 1868E. Haz venue Stoc California 95205 i T 209 468-3420 i F 209 464-0138 1 www.sicehd.com <br />