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SMJOAQUIN <br />Environmental Health Department <br />—COUNTY— <br />��Os Greatness grows {sere <br />Monitoring Well/Soil Boring Inspection Report <br />�hollp ,_ IDate: <br />D Inspector: ,NJ CONSTRUCTION <br />Facility Address: l ! IIS �__ II <br />Well Addresb Total Depth: 4 5 , , s' A <br />WP# �C Well#: Drilling Rig Type: 1—i <br />Soil Boring#: 31 <br />Min 2" Annular EHD Seal Verified: ❑Yes <br />Drilling Company: ❑ o <br />Screen Length From: To: <br />Driller Onsite: <br />Consultant: <br />Filter Pack From: To: <br />S � � Qo <br />Geologist: 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 />Verified Chain of Custody <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />Covered: <br />If yes, material: <br />GROUTING or DESTRUCTION Total D <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑Well Installation ❑ ell Destruction <br />Boring Installation ❑Boring <br />De <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity Aremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />eallons <br />Cement 941b <br />Bags <br />Thicker Thinnest <br />A <br />Thickest Thinnest <br />4Bags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />5 10 <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 1 25 <br />5 <br />25 50 <br />5 <br />130 <br />6 <br />30 60 <br />6 <br />7 <br />35 70 <br />S17L.55L]E5t <br />8 <br />40 80 <br />8 <br />COcasing <br />height <br />ABOE-GROUND CHRLSTY43OX- <br />act <br />— o <br />sionad <br />s.cson 5 �e <br />g-vw Pack <br />—ft. 2= tt. <br />s <br />MATERIALS/DEVELOPMENT <br />Casing Type: <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: M et- <br />CAr; S vo10-- vlGi l ai 5D . <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 />I I 1 �2" 62/10/16/2017 <br />` ilyif �'e /— u'� t7� ; l S <br />1868 E. Hazelton Avenue I Stockton, Califon is 95 T 20 -3420 1 F 209 464-0138 www.sucehd.com <br />