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SANGJ0AQUIN <br />_.COU NTY— <br />'� Grec-'.ness orov;s here. <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: (� Z3�� Inspect r:mo <br />CONSTRUCTION <br />Premise Address: <br />WP#: n Total Depth: 0 <br />Well#: Drilling Rig Type. :H <br />Soil Boring#: Min 2" Annular Seal Verified: L1 Yes ❑ No <br />Drilling Company: U <br />Driller Onsite: p Screen Length From: To: . <br />Consultant: -A E <br />Filter Pack From: To: <br />Geologist: eyN Bentonite From: To: <br />Grout From: To: <br />Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody <br />r1vnn e <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes ❑ N o <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />If yes, material: <br />r <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: .QS h• ) t bs G, <br />Grout Material: —&hea-f- Ce i; <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />El Boring Installation goring Destruction <br />nnFTunn i mr:n <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity T remie ❑Other: <br />'Hater <br />allons <br />Cement 471b <br />Bags r <br />Water <br />alons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />#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 />is <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 />2 5 <br />35 <br />35 <br />70 <br />7 <br />220 <br />40 <br />8 <br />40 <br />80 1 <br />8 <br />1868 E. Hazelton Avenue I Stockton, California 95205 <br />tL <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: _ <br />Filter Pack Type/Size: <br />Type of Method: <br />Screen Feet <br />BentoniteXement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 941b 2:82 .4.7 <br />Sln�e <br />/V, f 1<j -eCl Q s <br />Au 4MA <br />T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />