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QwN , <br />c° SAN_ JOAQUIN <br />Environmental Health Department <br />COUNTY <br />Greatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 20f Inspector: 0 CONSTRUCTION <br />Facility Address: a C) <br />Well Address- Total Depth: <br />WP# n 'l Well#: Drilling Rig Type: <br />Soil Boring#: <br />Drilling Company: I (' Min 2" Annular EHD Seal Verified: El Yes ❑No <br />Driller Onsite: `�J� Screen Length From: To: <br />Consultant: Filter Pack From: To: <br />Geologist: �entonite From: To: <br />Grout From: To: <br />Public Water System Onsite: ❑ Yes V�N0 <br />Domestic Well Onsite: ❑ Yes YfNo <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: <br />❑ Yes ONo <br />SPOILS <br />Cement 941b <br />Bags <br />Contamination Noted: <br />❑ Yes fNo <br />If yes, spoils storage Location: <br />4Bags <br />Covered: <br />1 <br />El Yes .;'J No <br />If yes, material: <br />COMPLETION ❑ Stove Pipe ❑Christie Box <br />casing <br />height <br />ABOVE -GROUND CtiH1STY 80X <br />COA�'LET30N comPLEnoN <br />orvvnd Surracs <br />grout <br />fi. <br />tt. _ <br />_ <br />alcrtaa <br />saceon — <br />�; _ grawi Fac3c <br />toff /0 d <br />GROUTING or DESTRUCTION Total Depth: . = <br />Depth to Water: I n' <br />Grout Material: j <br />Gallons of Grout Used: I TMATERIALS/DEVELOPMENT <br />❑Well Installation []Well Destruction <br />El Boring Installation Sporing Destruction <br />MFTNnn I ICF'r) <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity $Tremie.,er: <br />Water <br />allons <br />Cement 471b <br />Bas <br />Water <br />gallons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />4Bags <br />Thickest Thinnest <br />4Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 <br />8 <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 />