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' pill/�C° \ $QN c�0QQU IN Environmental Health Department <br /> ' "_ �) —COUNTY— <br /> i� Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date:141 -t� Inspector:. o'AlL CONSTRUCTION <br /> Facility Address: it-G `Z <br /> Well Address: Total Depth: <br /> Wpp Well#: Drilling Rig Type: <br /> Soil Bori tg#: Min 2"Annular EHD Seal Verified: ❑Yes []No <br /> Drilling Company: Screen Length From: To: <br /> Driller Onsite: f h <br /> Filter Pack From: To: <br /> Consultant: L Bentonite From: To: <br /> Geologist: r <br /> Grout From: To: <br /> Public Water System Onsite: ❑Yes .BNo COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑Yes EJN[o casing <br /> If yes,location and distance: height <br /> SAMPLING ABOVE-GROUND Crwlsrreox <br /> Holding Temperature: CONFaLETION COMPLETION <br /> ��t3rourd Ssxlac. <br /> Method: <br /> Screening Method: III, <br /> grout <br /> N. <br /> Verified Chain of Custody: ❑Yes ❑No N. <br /> SPOILS <br /> 7? = o <br /> Contamination Noted: ❑Yes ONo — <br /> If yes,spoils storage Location: .lot od L _ 8 <br /> aac.'on :pt = <br /> Covered: ❑Yes ❑No — QMW Patls <br /> If yes, material: <br /> per . . c <br /> GROUTING or DESTRUCTION Total Depth:[ <br /> Depth to Water: <br /> Grout Material: MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: '1' f R" 9 Casing Type: <br /> ❑Well Installation fVell 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 eOver Drill Filter Pack Type/Size: <br /> ❑ Gravity 2tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> allons Ba s allons Ba s <br /> Thickest Thinnest pBags Thickest Thinnest 9Bags Bentonite/Cement MIX 3%MIX 5%Mix <br /> 2.5 5 1 5 to I 1 I Bentonite per 47 Ib 1 J.411 2.47 <br /> 5 10 2 10 20 2 1 Bentonite per 941b 1 2.821 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 /> 15 30 6 30 60 6 <br /> 17.5 35 7 35 70 7 <br /> 20 40 a 4o eo a 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sucehd.com <br />