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°� SANgJOAQUIN Environmental Health Department <br /> —COUNTY- <br /> 1.. <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date:�'L Inspector: CONSTRUCTION <br /> Facility Address:it <br /> Well Address: Total Depth: <br /> Wp# /�a10� Well#:`��-1 Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No <br /> Drilling Company: f mSG a1a.A Screen Length From: To: <br /> Driller Onsite: ��� ^ Filter Pack From: To: <br /> Consultant: htL <br /> � Bentonite From: To: <br /> Geologist: >ov <br /> Grout From: To: <br /> Public Water System Onsite: ❑Yes 121No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes 1�No casing <br /> If yes,location and distance: Ifftl <br /> height <br /> I <br /> SAMPLING ABOVE-GROUND CHRi5 43OX <br /> Holding Temperature: CONWLErION COMPLEnoN <br /> �__aroum ssrlacs <br /> Method: <br /> Screening Method: grout <br /> .�_n. <br /> Verified Chain of Custody: ❑ Yes ❑No It. <br /> SPOILS <br /> A <br /> Contamination Noted: ❑ Yes Mo <br /> If yes,spoils storage Location: slotted EE <br /> section <br /> Covered: ❑Yes ❑No __ 9—Haack <br /> If yes,material: — <br /> GROUTING or DESTRUCTION Total Depth:_ <br /> Depth to Water: 10 <br /> tt. tt. <br /> Grout Material: 1,) MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: U 3 Casing Type: <br /> ❑Well Installation 4?rWell Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> El Boring Installation ❑Boring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> El Pressure Grout ZfOver Drill Filter Pack Type/Size: <br /> ❑ Gravity I2 I remie ❑Other: Type of Method: <br /> Water Cement 471bM <br /> Cement 941b <br /> allons Ba SBa sThickest Thinnest ueagsest uBags Bentonite/Cement MIX- 3% MiX 5%MIX2.5 5 1 1 Bentonite per471b 1.41 2.475 10 2 2 Bentonite er 941b 2.82 4.77.5 15 3 310 20 4 412.5 25 5 515 30 6 617.5 35 0 720 40 8 o 0 <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.secehd.com <br />