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SAN�J0A OU •'y�`` Environmental Health Department <br />—COUNTY— <br />;\�� t.`• G,-cctness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date:, I I I Inspector: CONSTRUCTION <br />Facility Address: - _ <br />Well Address: Total Depth: <br />WP# Well#: Drilling Rig Type: <br />Soil Boring#:',^•� <br />Drilling Company:WOOD* WL Min 2" Annular EHD Seal Verified <br />Driller Onsite: NAN Screen Length From: <br />Consultant: Filter Pack From: <br />Geologist: \/i D <br />Bentonite From: <br />Grout From: <br />Public Water System Onsite: <br />Domestic Well Onsite <br />If yes, location and distance: <br />SAMPLING <br />Holding emperature:_ <br />Meth d: <br />Irified <br />ning Method: <br />Chain of Custody: <br />,Pnn <br />Contami ation Noted: <br />If s, spoils storage Location: <br />C vered: <br />If yes, material: <br />❑ Yes ❑No COMPLETION ❑ Stove Pipe <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />GROUTING o DESTRUC Jsi<l Tooal Depth: a �� ✓• t <br />Depth to Water: iT? 1:\l �9'C,'•S <br />Grout Material: t\e CP -.A\ �i �� 2 ST <br />Gallons of Grout Used: s0000 t <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Aoring Destruction <br />METHOD USED <br />❑Pressure Grout Dover Drill <br />LrGravity ❑Tremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Baas <br />Water <br />wall ons <br />Cement 941b <br />Bags <br />Thickest Thinnest <br />4 Bags <br />Thickest Thinnest <br />Al Bags <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 />A <br />20 <br />40 <br />4 <br />12.5 X <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 />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />El Christie Box <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 />1368 E. Hazelton Ayenu�I Stockton, Calif&riia 95205 [ T 209 468-34201 F 209 464--0138 1 www.sicehd.com <br />