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EnvironmentM Health Department <br /> —coUNTY— <br /> Greotness ,9rorrs here ection Report <br /> Monitoring Nell/Soil Boring Insp <br /> Ins pecto�;j CQNSTR�UCTION <br /> Date: F. C y Total Depth: <br /> Facility Address: Drilling Rig Type: <br /> Well Addre Weilff: y Verified: El Yes ONO <br /> WG min r Annular EHD Seal To:� <br /> Soil Boring#: <br /> Drilling Company OL Screen Length From: <br /> rn <br /> Filter Pack From: To.. <br /> Driller Onsite Bentonite Fronn:� TO' <br /> Consultant:-A - flovp Grout From:� To:_� <br /> Geologist: 6L V I" DChristie Box <br /> COMA <br /> stove ❑Pipe <br /> Public Water system Onsite: D Yes DNo <br /> cas;3.119 <br /> Domestic Well Onsite: El Yes EINo + <br /> If yes,location and distance: 17 <br /> C418iSTYtx- <br /> AppYEiiAOUNO COMPLEMN <br /> SAMPLING <br /> Holding Temperature: ------- Grout <br /> Method- ft. <br /> Screening Method: <br /> Verified chain of Custody: Yes ONO -a . <br /> A <br /> SPOILS ❑ <br /> yes EINo _a Z�j Z= <br /> Contamination Noted: <br /> alottadIf yes,spoils storage Location:------- QMVV1 Pack <br /> Dyes ONO <br /> Covered: <br /> If yes,material:--� Depth' so <br /> GROUTING or DESTRUCTION Total <br /> Depth to <br /> e-�R <br /> IVIATERIAL—SPDEV�ELOPMNT <br /> Grout Material:::W Casing Type: Feet <br /> --------- ------- <br /> Gallons of Grout Used: Blank�Feet Screen� <br /> oWell installation Well Destruction Slot Size; <br /> Bags of cement: <br /> L-jBorIng Installation DBormg Destruction Bags Sand/Gravel: <br /> Type/Brand of Bentonite: ------ <br /> METH— Filter Park Type/Size: <br /> Dpressure Grout Dover Drill Type of Method: ------ <br /> El Gravity rgTrernie Dother: <br /> Water cement941b <br /> Water cement 471h Be <br /> aeonssa 5 a11°ns <br /> hinnest a Bags <br /> thickest <br /> ,Wck,,t -ih1nnast _ #Bags -- 10 <br /> 1 <br /> 15 5 10 20 <br /> 5 10 2 is 30 3 <br /> 5 is 3 20 40 4 <br /> 1 20 4 25 50 5 <br /> 125 25 5 so 60 6 <br /> AD 1 35 70 7 10/16/20I7 <br /> 35 7 40 80 a <br /> 0 40 a I Stockton,California 952051 T 209 468-3420 1 F 209 464-0138 w%W.sjcehd,coM <br /> 1868 E.HazeltOn A"""' <br />