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Y <br />N , SANJOAQUIN <br />Environmental Health Department <br />—COUNTY— <br />, <br />n <br />Greotess gror5s dere. <br />Moni <br />toring Well/Soil Boring Inspection Report <br />Date:Inspector: CONSTRUCTION <br />Facility Address: dhet I.L <br />Well Address: w4 UP_ S '� <br />wP# w II#: t <br />Soil Boring#: <br />Drilling Company: - j <br />Driller Onsite: <br />Consultant: L P <br />Geologist: Q <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 />C; -P-14 otal Depth: �- _ i� d t" C ty <br />Drilling Rig Type <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />From: <br />Filter Pack <br />From: <br />Bentonite <br />From: <br />Grout <br />From: <br />❑ Yes El No COMPLETION ❑ Stove Pipe <br />❑ Yes ❑No <br />❑ Yes ❑ No <br />Contamination Noted: ❑ Yes El No <br />If yes, spoils storage Location: <br />Covered: ❑ Yes ❑ No <br />If yes, material: /' ) <br />GROUTING or DESTRUCTION Total Depth: V <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: U1►1S <br />❑Well Installation ❑Well Destruction <br />❑Boring InstallatioV4Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity 4Tremie ❑Other: <br />Water <br />allons <br />Cement 47 lb <br />Bas <br />Water <br />qa1111 ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />ttBags <br />Thickest Thinnest <br />4 Bags <br />2.5 5 <br />1 <br />5 10 <br />1 <br />10 <br />C2 <br />10 20 <br />2 <br />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 1 35 <br />7 <br />35 70 <br />7 <br />20 1 40 <br />8 <br />40 80 <br />8 <br />❑ Yes ❑Nc <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 />ft. <br />Screen Feet <br />Bentonite/Cement Mix 3% Mix 3% 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.secehd.com <br />