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SAN�JOAQUIN Environmental Health Department —COUNTY— Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date. I In pectora floCONSTRUCTION Facility dies :� Well Ad-dress: Total Depth: WP# r� Well#: Drilling Rig Type: Soil Boring#: s 11 Min 2"Annular EHD Seal Verified: El Yes ❑No Drilling Company: Driller Onsite: Screen Length From: To: Consultant: Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: height 31T— T SAMPLING AovE-GROUND Holding Temperature: COWLET;CN COMPLFTiON Method: GrDC7nd Ste"' Screening Method: ;rout Verified Chain of Custody: ❑ Yes ❑Nott' ts. ft. SPOILS Contamination Noted: ❑ Yes ❑No If yes, spoils storage Location: Covered: ❑ Yes ❑No = . g-vlw pads If yes, material: � -�- GROUTING o ESTR C Total Depth: B15`Co� IF ; FE - Depth to Water77RAPCI ft. Grout Material: neat Gallons of Grout Used: i3�'1. RIALS DEVELOPMENT Ii�g Type: ❑Well Installation ❑Well Destruction Big_ Feet Screen Feet Slot Size: ElBoring Installation Aoring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: I� Gravity ❑Tremie ❑Other: Type of Method: �� Water Cement 47lb Water Cement 94 lb gallons Bags "lions Bags Thickest Thinnest "Bags Thickest Thinnest kBags Bentonite/Cement Mix 3% Mix 5% Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 s 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 7.5 15 3 15 30 3 Amp 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 6 00 0 94 ba s tD 10 - Iv��l l� r- ��cl� /1- i117 1868 E. Hazelton Avenue I Sockton, California 95205 1 T 209 468-3420 1 F 209 464/fi0138 1 www.sicehd.com