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$ANJOAQUIN Environmental Health Department <br /> —COUNTY <br /> Greatness grows here. <br /> J <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: to nspector: V-J CONSTRUCTION l <br /> Facility Address: ( ( t <br /> Well Add ess Total Depth: d <br /> WP# Well#: f Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ONO <br /> Drilling Compan Screen Length From: To: <br /> Driller Onsite: y: Filter Pack From: To: <br /> Consultant: <br /> Bentonite From: To: <br /> Geologist: r <br /> L Grout From: To: <br /> Public Water System Onsite: ❑Yes ONO COMPLETION ❑ Stove Pipe El Christie Box <br /> Domestic Well Onsite: ❑Yes ❑No casing <br /> If yes,location and distance: � height <br /> SAMPLING ABOVE-GROUND CHRMN-BOX <br /> Holding Temperature: COtJlF'LETION COMPLETION <br /> Ground surx. —� � <br /> Method: grout <br /> Screening Method: <br /> ry. <br /> Verified Chain of Custody: ❑ Yes ❑No ry, <br /> _tt. — <br /> SPOILS = T . <br /> Contamination Noted: ❑ Yes ONO ° =_ <br /> If yes,spoils storage Location: <br /> s <br /> stoned `'i = .8 <br /> secdon k <br /> Covered: ❑Yes ❑No - a.ava pads <br /> If yes,material: Jr <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: tt. <br /> Grout Material: 0 MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> El Boring Installatio g Destruction Bags of Cement: <br /> METHOD USED <br /> Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> ❑ Gravity ❑Tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement941b <br /> allons Bags gall is Rees _ <br /> Thickest est #Bags Thickest Thinnest #Bags Bentonite/Cernent MIX 3%MIX 5%MIX <br /> 2.s 1 s 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> 5 0 2 10 20 2 Bentonite er 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 B 40 80 B <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.socehd.com <br />