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SANdOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> r <br /> Date: Inspector: Iv CONSTRUCTION <br /> Facility A dress: "t <br /> Well AddreFs: Total Depth: <br /> yyp#--A�� Well#: 5" Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑Yes ❑No <br /> Drilling Company: La5 G Screen Length From: To: <br /> Driller Onsite: v Filter Pack From: To: <br /> Consultant:_ <br /> Geologist: 'S v� Bentoni To: <br /> te From: <br /> Grout From: To: <br /> Public Water System Onsite: ❑Yes rO No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes la No casing <br /> If yes, location and distance: height <br /> SAMPLING ABOVE-GRCUND CHglsrr-sox <br /> Holding Temperature: COWPLE ION CCMP1ETICN <br /> Grouts Ssrlx0 <br /> Method: ors <br /> Screening Method: <br /> Verified Chain of Custody: ElYes ❑No �---n <br /> n. <br /> SPOILS <br /> Contamination Noted: ❑ Yes 0 No <br /> If yes,spoils storage Location: .lortad <br /> Covered: ❑ Yes El No — gravalpads <br /> If yes, material: _ <br /> GROUTING or DESTRUCTION Total Depth: �� n <br /> Depth to Water: n' <br /> Grout Material: MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: ^ <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 of Bentonite: <br /> ❑Pressure Grout Clover Drill <br /> Filter Pack Type/Size: <br /> ,❑ Gravity 116Tremie ❑Other: Type of Method: <br /> Water Cement 471h Water Cement 941b <br /> Iluns BagsIfln <br /> Ba s <br /> Thlckest Thinnest Mils est aBags BentonitelCement Mix 3% Mlx <br /> 2.5 5 1 1 Bentonite er 47 Ib 1.41 2.475 10 2 2 Bentonlle er 94 Ib 2.82 4.775 15 3 310 20 4 412.5 25 5 515 30 6 617.5 35 7 72019 40 a 3 <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 />