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Environmental Health Department <br />—COUNTY— <br />.r <br />Greatness orcFvs here. <br />r j Monitoring Well/Soil Boring Inspection Report <br />Date: 1 / r✓ Inspector: �� CONSTRUCTION <br />Premise Address: 3 r <br />WP#: © U Total Depth: 1 <br />Well#: Drilling Rig Type: <br />Soil Boring#: 2 <br />Cement 471b <br />Sags <br />Min 2" Annular Seal Verified: <br />Drilling Company: <br />Cement 941b <br />Bais <br />Driller Onsite: <br />Screen Length From: <br />Consultant: <br />Filter Pack From: <br />Geologist: ���yv/\ <br />Bentonite From: <br />1 <br />Grout From: <br />Public Water System Onsite: <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 />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />❑ Yes ❑No COMPLETION ❑ Stove Pipe <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depi th: <br />-- <br />Depth to Water: L <br />Grout Material: r..r/V1A <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation�Boring Destruction <br />nnFTunn i icFn <br />❑Pressure Groutt�❑Over Drill <br />ElGravity I i ramie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Sags <br />Water <br />gallons <br />Cement 941b <br />Bais <br />Thickest Thinnest <br />:t Bags <br />Thickest Thinnest <br />9Bags <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 />30 <br />60 <br />6 <br />7.5 1 <br />35 <br />7 ' <br />35 <br />70 <br />7 <br />20 1 <br />40 <br />40 <br />90 <br />8 <br />❑ Yes El No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <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 />Bentonite/Cement Mix 3% Mix 5% Mix <br />_ Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2:82 4.7 <br />-7q j,;75ee b 5 �� 70 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />