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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: �� (� Inspector: a�m I -P <br />Facility Address: <br />Well Address: <br />31� <br />G• CQRPA 1 lU <br />WP# ) <br />Cement 94 lb <br />Bags <br />Well#: <br />Soil Boring#: <br />G <br />»Bags <br />Drilling Company: Term <br />cot <br />Driller Onsite: <br />�ZO <br />1 <br />Consultant: <br />WA <br />c_ <br />Geologist: <br />S POWIEA-' <br />7.5 <br />$ioL0(D(C_ <br />: &NO <br />t-OSTA <br />Public Water System Onsite: ❑ Yes IINo <br />Domestic Well Onsite <br />If yes, location and distance: <br />SAMPLING <br />Holding Te erature: <br />Method: <br />Screeni Method: <br />❑ Yes Elo <br />Verific(d Chain of Custody: ❑ Yes ❑Nc <br />SPOILS <br />Contaminati n Noted: <br />If yes, s oils storage Location: <br />Covered <br />If ye , material: h��L <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: --- <br />Grout Material: 02Ckf C*1QMQ-Nt_ <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />Gallons of Grout Used:G <br />❑Well Installation ❑Well Destruction <br />�poring Installation ❑Boring Destruction <br />MF:TNnn I im:n <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity ❑Tremie Other: <br />Water <br />allons <br />From: <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 94 lb <br />Bags <br />Thickest Thinnest <br />4Bags <br />Thickest Thinnest <br />»Bags <br />2.5 <br />5 <br />1 <br />5 10 <br />1 <br />5 <br />10 <br />2 <br />10 20 <br />2 <br />7.5 <br />15 <br />3 <br />15 30 <br />3 <br />10 <br />20 <br />4 <br />20 40 <br />4 <br />12.5 <br />25 <br />5 <br />25 50 <br />5 <br />15 <br />30 <br />6 <br />30 60 <br />6 <br />17.5 <br />35 <br />7 <br />35 70 <br />7 <br />20 <br />40 <br />8 <br />40 80 <br />8 <br />rnNCTRI IrTInN <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified: ❑ Yes El No <br />Screen Length <br />From: <br />To: <br />Filter Pack <br />From: <br />To: <br />Bentonite <br />From: <br />To: <br />Grout <br />From: <br />To: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />-ft. <br />MATERIALS/DEVELOPM ENT <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 />10/16/2017 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />