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SAN JOAQUIN <br /> Environmental Health Department <br /> .� <br /> —COUNTY-- <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspector: ✓ CONSTRUCTION <br /> Facility Address: ZbLZZ. E /�,r✓L�e� <br /> Well Address: Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: Min 2"Annular EHD Seal Verified: ❑ Yes El No <br /> Screen Length From: To: <br /> Driller Onsite: Filter Pack From: To: <br /> Consultant: <br /> Geologist: Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes ❑No casing <br /> If yes, location and distance: height <br /> wig _QWT1 <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: COMPLETION coMPLET►oN <br /> Method: Ground Sulacs <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes ❑No ft' <br /> n. <br /> ft. <br /> SPOILS <br /> Contamination Noted: ❑ Yes ❑No <br /> If yes, spoils storage Location: sbn�d <br /> sac�cn <br /> Covered: ❑ Yes El No _ <br /> If yes, material: <br /> 4. <br /> GROUTING or DESTRUCTION Total Depth: , <br /> Depth to Water: ' <br /> Grout Material: <br /> MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> ,_ <br /> � Casing Type: <br /> [W ell Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slat Size: <br /> ❑Boring Installation ❑Boring Destruction <br /> Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity f_, remie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> allons Bas gallons Bags <br /> Thickest Thinnest NBags Thickest Thinnest riBags Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 <br /> 7,5 15 3 15 30 3 <br /> 10 20 4 20 40 4 <br /> 12.5 25 5 25 50 5 <br /> 1. 30 7 30 70 6 /�, <br /> 17.5 35 7 35 70 7 / LJ — �7 p Ilk <br /> 20 40 8 40 80 8 ` �1 vC� <br /> p r 10/16/2017 <br /> 5 4.�•��I,o� � Sv Lb if ak,�n Si+e�,.{{, � X46814201 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T F 209 464-0138 1 www.sicehd.com <br /> t go.- /Z LMS 0 1 <br />