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5AN JOAQU I N Environmental Health Department <br /> —CCU i`J T Y— <br /> Monitoring Well/Soil Boling Inspection Report <br /> Date:" 1 IIOJL4 Inspector: V - V CONSTRUCTION <br /> Premise Address: MU UII U fa�>(I <br /> WP#:��f'�7����' 'r Total Depth: <br /> Well#: (_ " Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular Seal Verified: ❑ Yes ❑No <br /> Drilling Company; C <br /> Driller Onsite: c'•`C Screen Length From: To: <br /> Consultant: Filter Pack From: To: <br /> Geologist: tlP, � CIA mAlk <br /> Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes ❑No oasirg <br /> If yes, location and distance: ,jH-T height <br /> , <br /> SAMPLING AWv>=.3ROUNQ _ <br /> Holding Temperature: coy``' LEriON CC I.mmart <br /> Method: G=.jrd S"1"* ' <br /> Screening Method: �r«n <br /> Verified Chain of Custody: ❑ Yes ❑No ft. <br /> ft. <br /> _ ft. <br /> SPOILS <br /> Contamination Noted: ❑ Yes ❑No — <br /> a`` c <br /> If yes'spoils storage Location: <br /> ilnttnd — � <br /> n "' = <br /> Covered: ❑ Yes El No =r <br /> vyt Pack <br /> If yes, material: 5EE <br /> x- — <br /> GROUTING or DESTRUCTION Total Depth: =_ <br /> Depth to Water: ft• -ft. <br /> Grout Material: <br /> Gallons of Grout Used: 10056 MATERIALS D EVELP PM ENT <br /> Casing Type: V(174�1 <br /> C gell Installation ❑Well Destruction Blank Feet Screen Feet <br /> II _ Slot Size: <br /> ❑Boring Installation ❑Boring Destruction Bags of Cement: `�Z ��[6 L-ni'&'( <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> ❑ Gravity �Zremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> allons Bags gallons Bags <br /> Thickest Thinnest #Bags Thickest Thinnest 4aggs <br /> 2.5 5 1 1 5 10 1 Bentonite/Cement Mix 3% Mix 5% Mix <br /> 5 10 1 2 10 20 2 Bentonite per 47 Ib 1.41 2.47 <br /> 7.5 is 3 15 3o 3 <br /> 10 20 4 20 40 4 Bentonite per 54 Ib 1 2.82 4.7 <br /> 12.5 25 5 25 50 5 <br /> 15 30 6 1.0 60 6 <br /> 17.5 35 7 35 i 70 I 7 <br /> 20 40 $ 40 n, $ <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.coin <br />