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SAN . J OA Q U I N Environmental Health Department <br />r; -COUNTY— <br />Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: Inspector: V� CONSTRUCTION <br />Facility Address: �+✓ `b (`� <br />Well Address: - Total Depth: 2.0 11 <br />WP#Well#: IriQDrilling Rig Type:8 <br />Soil Boring#: Min 2" Annular EHD Seal Verified: ❑ Yes El No <br />Drilling Company: <br />Driller Onsite: r Screen Length From: To: <br />Filter Pack From: To: <br />Consultant: <br />Geologist: 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 <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody: <br />CY•SS71Cy <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />If yes, material: <br />GROUTING or DESTRUCTION T tal Depth: -� <br />Depth to Water: l'ee Y"' <br />Grout Material: s- ctck— <br />Gallons of Grout Used: <br />24ell Installation ❑Well Destruction <br />❑Boring Installation ❑Boring Destruction <br />MFTunn I ICFn <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity I<emie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />1t Bags <br />Thickest Thinnest <br />"Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />4D <br />80 <br />8 <br />casing <br />height <br />A 30VE-GROUND CHRZTY43OX <br />COMPLETION cOMPLE noN <br />Ground surface <br />grout <br />,,,, P�Zzr"� <br />Ii n ab =. <br />n Ct�4­ Off. <br />a r <br />MATERIALS/DEVELOPMEi' T-' <br />LIC Type: 7-' l L/ K'f ' <br />Blank Flet /r Screen Feet <br />Slot Size: / <br />Bags of Cem t: <br />Bags San Grav <br />Type/ and Bentonite: <br />Fil r Pac Type/Size: <br />Type of Method: <br />Bentonite/Cement Mix 3% Mix 3% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <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 />