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,z F�w��`�:;, SAN�JOA UIN Environmental Health Department COUNTY— Greatness grows here. • Monitoring,,Well/Soil Boring Inspection Report Date: I Inspector: L 1 NJ 0 CONSTRUCTION Facility Address: IvIW av¢,. Well Address: ih Total Depth: WP#n 0 010 Well#: Drilling Rig Type: Soil Boring#: t166 P91ra0 OD Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Yr a Cd'1 Driller Onsite: 0 Screen Length From: To: Consultant: _TQ.'(f G Filter Pack From: To: Geologist: C 14 W,S 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 ' T T i SAMPLING AsoVE-GROUND Holding Temperature: .�t�t�—n°tv COMPL_ETjON Method: saround sumacs Screening Method: or«n Verified Chain of Custody: ❑ Yes ❑No ft. SPOILS Contamination Noted: ❑ Yes ❑No - — If yes, spoils storage Location: :[orad n Covered: ElYes ❑No If yes, material: . GROUTING or DESTRUCTION Total e De thSix 6= 0 p 1 T` Depth to Water: 10 R_Af_l – –ft- Grout Material: a'r r j–�� MATERIALS/DEVELOPMENT Gallons of Grout Used: r�11w) �<< 4�i' Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation Boring Destruction Bags iz Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity ITremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bags wall ons Batts Thickest Thinnest kBags Thickest Thinnest Bags Bentonite/Cement Mix 3% Mix 5% MIX 2.5 5 1 5 10 1 Bentonite per 47 Ib 1 1.411 2.47 5 10 2 10 20 2 Bentonite per 94 Ib 2.821 4.7 7.5 15 3 15 30 3 1. 20 4 20 40 4 I G�IDhJ �" �'J l nl.G 1 25 5 25 50 5 155 30 6 30 60 6 /�✓ J 17.5 35 7 35 70 7 V 20 40 8 40 80 8 10/16/2017 1368 E. Hazelton Avenue I Stockton,California 95205 [ T 209 46&3420 1 F 209 464-0138 I www.sicehd.com