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(_ SAN JOAQUIN Environmental Health Department COUNTY Greotness grows here. Monitoring Well/Soil Boring Inspection Report Date: 7-'E>-LI Inspector: n`'St*"" CONSTRUCTION Facility Address: 5'135' 1Q11exa�.rAt,u Well Address: Total Depth: WP#t'43'It1`19,j 3'lyr/ Well#: 1, 2 Drilling Rig Type: Soil Boring#: Min 2" Annular EHD Seal Verified: ❑ Yes El No Drilling Company: Screen Length From: To: Driller Onsite: li�w Consultant: Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes El No casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: COAFLErION COMPLEN no Method: Ground Stafw* Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No —tt' R. tt. SPOILS Contamination Noted: ❑ Yes ❑No If yes, spoils storage Location: slotted :s aeon Covered: ❑ Yes ❑No g-vell pack If yes, material: GROUTING or DESTRUCTION Total Depth: 11 Depth to Water: l3 ` tt. Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: I�Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation ❑Boring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: ❑ Gravity ❑Tremie Other: Fo lt4l� Type of Method: at ent 471 Water Cement 94 lb ns Bas allons Bags Thickest Thinnest ✓r Bags Thickest Thinnest stBags Bentonite/Cement Mix 3% Mix 5% Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 1 25 5 25 50 5 15 1 30 6 30 60 6 17.5 35 7 35 70 7 20 40 8 40 80 8 5- -X6 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.s4cehd.com