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SAN J OAQ U I N Environmental Health Department COUNTY Monitoring Well/Soil Boring Inspection Report Date: Inspector: ^t`E"t- CONSTRUCTION Facility Address: 1..,#te / Well Address: Total Depth: WP# 4."03:Ky Well#: Drilling Rig Type: Soil Boring#: r3l, 2 Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Driller Onsite: Screen Length From: To: Consultant: q//�� KkU Filter Pack From: To: Geologist: Bentonite From: To: g $ Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes,location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: COM'�ION �1.Enc;N Method: Ground Suriacs Screening Method: orout Verified Chain of Custody: ❑ Yes ❑No —`'—n' n. n. SPOILS _ Contamination Noted: ❑ Yes ❑No = r If yes,spoils storage Location: slonea atc"cn _ Covered: ❑ Yes ❑No = a,,9t Pack If yes, material: ` Y GROUTING or DESTRUCTION Total Depth: iJ : • Depth to Water: Grout Material: () L whew MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation RBoring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: f Filter Pack Type/Size: [I Gravity ❑Tremie Xothef+�!"* it Type of Method: at a nt 4 Water Cement 941b alto Bas vallons Bags Thi est Thinnest i Bags Thickest Thinnest >tBaBs 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 25 1 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 1 70 7 20 40 1 8 40 1 80 6 SD 15- 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com