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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date:�� ( 7 Inspector: v� CONSTRUCTION <br /> Facility A ress: '�00 _!5 j Lo, C <br /> Well Address: Total Depth: — / '� 0 <br /> WP# S Well#: Drilling Rig Type: b Cyt <br /> Soil Boring#: Min 2" Annular EHD Seal Verified: ❑ Yes El No <br /> Drilling Company: <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: Filter Pack From: To: <br /> Geologist: r Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes ❑No casing <br /> If yes, location and distance: height <br /> SAMPLING ABOVE-GROUND ___ <br /> Holding Temperature: COWLETION COMP=CN <br /> Method: Ground Surface T <br /> Screening Method: gr«n <br /> Verified Chain of Custody: E__1Yes El No �ft' <br /> tt. <br /> ft. <br /> SPOILS = <br /> Contamination Noted: ❑ Yes El No <br /> If yes, spoils storage Location: a�n�e <br /> a cn <br /> Covered: ❑ Yes El No <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: "7 <br /> IF <br /> Depth to Water:—7'6.c,,- <br /> Grout Material: LU,P,.wX �� MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation Boring Destruction Bags iz Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill C Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity ��remie ❑Other: Type of Method: <br /> ll� <br /> Water Cement 471b water Cement 941b Pv f <br /> allons Bas allons Bas I AA 0' If, r �v/Vs'o a hptd►Z <br /> Thickest Thinnest #Bags Thickest Thinnest bBags I 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 BerAonite per 94 Ib 2.82 4.7 <br /> 15 3 15 30 3 <br /> 10 <br /> 10 20 4 20 40 4 r/ r� [C) __�v <br /> 12.5 25 25 50 5 <br /> 15 30 6 30 60 6 <br /> 17.5 35 7 35 70 7 <br /> 20 40 s 40 so a <br /> �LAi 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />