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SQN_JOQQUIN Environmental Health Department <br />—COUNTY— <br />� r; Grevtness groves here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: .S���r� Inspector: Vj 0, CONSTRUCTION <br />Facility Address: <br />Well Address: Total Depth: <br />WP# 0 5­1�v Well#: Drilling Rig Type: <br />Soil Boring#: <br />Drilling Company: Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br />Driller Onsite: Screen Length From: To: <br />Consultant: Filter Pack From: To: <br />Geologist: Bentonite From: To: <br />Public Water System Onsite: El Yes 40Grout From: To:COMPLETION ❑ Stove Pipe ❑Christie Box <br />Domestic Well Onsite: <br />If yes, location and distance: <br />❑ Yes L jV0 <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: ❑ Yes ❑No <br />SPOILS <br />Contamination Noted: ❑ Yes El No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes El No <br />If yes, material: <br />GROUTING or DESTRUCTION Total e the P s q <br />Depth to Water: V (J <br />Grout Material: CR WAL(l <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring InstallationNQBoring Destruction <br />Y%nnFTWM I ICFn <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity Wremie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />vallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />#Bags <br />Thickest Thinnest <br />#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 />30 60 <br />6 <br />17.5 35 <br />35 70 <br />7 <br />20 40 <br />8 <br />40 80 <br />8 <br />ft. <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 1.411 2.47 <br />Bentonite per 94 Ib 2.821 4.7 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 <br />V V <br />16/2017 <br />SI www. s'h .com <br />