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S OOAQUIN AN Environme I Health Department —COUNTY- - Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date: Inspector: CONSTRUCTION Facility Address: \5'Z�a knM� Well Address: Total Depth: WP# `'to�zj� Well#:V\,'�& Drilling Rig Type: Soil Boring#: V---) /P+ Drilling Company: �-�c'-�L'Pc0'�G. Min 2"Annular EHD Seal Verified: El Yes []No Driller Onsite: �� Screen Length From: To: Consultant: FiltP,Pack From: To: Geologist: 13e0tonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes fONo COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: �1 Yes ❑No casing If yes, location and distance: 2� height 77 SAMPLING wsovE-GROUND Holding Temperature: COMPLErlON CaWLETiON Method: Ground Sudacs Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No ft. ft. fi. SPOILS 4. � = m Contamination Noted: ❑ Yes El No If yes, spoils storage Location: sbnod = sac^..on "— Covered: ❑ Yes ❑No - gi-, If yes, material: s.. GROUTING or DESTRUCTION Total Depth: IF _= Depth to Water: t� 1 fL IF Grout Material: v '< Gallons of Grout Used: .i: IkSO A MATERIALS/DEVELOPMENT Casing Type: []Well Installation Owell Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation ❑Boring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout Over Drill Filter Pack Type/Size: ❑ Gravity iTremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b gallons Bags gallons Bags Thickest Thinnest ttBags Thickest Thinnest #Bags Bentonite/Cement Mix 3% MIX 5% MIX 2.5 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 5 10 2 10 20 2 Bentonite per 94 lb 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 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.sicehd.com