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SKJOAQUIN Environmental Health Department <br />COUNTY <br />Monitoring Well/Soil Boring Inspection Report <br />Date:+/ Inspector: CONSTRUCTION � <br />Facility Address: 44 -fl <br />Well Address: Total Depth:mll <br />/� t <br />WP# Well#: Drilling Rig Type: (� 5 d .a_ SSA , Q I . �, <br />'tM+ <br />Soil Boring#: �---- <br />Drilling Company: �� Min 2" Annular EHD Seal Verified: El Yes EJ No rr,n <br />Driller Onsite: a Screen Length From: To: <br />Consultant: Filter Pack From: To: S �� <br />Geologist: -.Qn/` Bentonite From: To: <br />Grout From: To: <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 />❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br />❑ Yes ❑No <br />Verified Chain of Custody: ❑ Yes ❑No <br />SPOILS <br />Contamination Noted: ❑ Yes ❑No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />E --]Well Installation ❑Well Destruction Uc <br />❑Boring Installation ❑Boring Destruct' n 11 <br />METHOD USED je <br />❑Pressure Grout ❑Over Drill Aa���5 <br />❑ Gravity rkremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />water <br />aallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />NBags <br />Thickest Thinnest <br />J1 Bags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 10 <br />2 <br />10 20 <br />2 <br />7.5 15 <br />3 <br />15 30 <br />3 <br />10 20 <br />4 <br />20 40 <br />4 <br />12.5 25 <br />5 <br />25 50 <br />5 <br />15 30 <br />6 <br />30 60 <br />6 <br />17.5 35 <br />7 <br />35 70 <br />7 <br />20 40 <br />8 <br />40 80 <br />8 <br />casing <br />height <br />ABOVE -GROUND C4iRISTY43OX <br />.. - <br />A SLOWS <br />-e-kw"o <br />f -o <br />/VD9reL <br />rea d <br />'w <br />— o <br />aloctad _ � <br />aeon <br />I_= : = prawl pack <br />ft. <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />it. <br />Blank Feet Screen 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 />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 />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.smcehd.com <br />