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SA N J OAQ U I N Environmental Health Department t' --COUNTY Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date: 2 u Inspect ,-. i CONSTRUCTION Facility A dress: Well Address: Total Depth: WP# Well#: Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Driller Onsite: Nh n w\a L. Screen Length From: To: Consultant: Filter Pack From: To: Bentonite From: To: Geologist: I Grout From: To: i Public Water System Onsite: ❑Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes,location and distance: height SAMPLING A WVE-GaoUNC CrtRIM-eox Holding Temperature: CO&FLETION COMPLETION Method: oroond su lets 7 Screening Method: Oran Verified Chain of Custody: ❑ Yes ❑Nott' tt. SPOILS a Contamination Noted: ❑Yes ❑No If yes,spoils storage Location: .bread j' �scdon Covered: ❑Yes ❑No __ pravd Pack If yes,material: GROUTING or DESTRUCTION Total Depth: 'l a b J am.�I, •� Depth to Water: Grout Material: 2 MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: e: ❑Well Installation Well Destruction Ll: ib yo,>Blank Feet Screen Feet ❑Boring Installation ❑Boring Destruction 5 alb��$Slot Size- Bags Bags of Cement: METHOD USED y �b Sand/Gravel: *ressure Grout ❑ Filter Pack TyOver Drill jType/Brand p Bentonite: Type/Size: ❑ Gravity ❑Tre i ❑Other: Type of Method: M20 r ement471b Water Cement941b ns Ba s allons Bags Thinnest ags Thickest Thinnest nBa� BentonitelCement Mix 3% Mix 5°/a ix e 1 s 10 1 Bentonite er47lb 1.41 2.47 10 2 10 20 2 Bentonite per 94Ib 2.82 4.7 15 3 15 30 3 20 4 20 40 4 25 5 25 so 5 30 6 30 60 6 35 7 35 70 7 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,s'cehd.com