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SAN J OA Q U I N Environmental Health Department COUNTY Monitoring Well/Soil Boring Inspection Report Date: _r 2 inspector; ,�-ett CONSTRUCTION Facility Address: Well Address: Total Depth: WP# DDA1111i Well#: Drilling Rig Type: Soil Boring#: p Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: V Driller Onsite: �L Screen Length From: To: Consultant: Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes El No casing If yes, location and distance: WT height SAMPLING ABOVE-GROUND Holding Temperature: CON'�ION LEMN Method: Ground Suaiaco Screening Method: oro Verified Chain of Custody: ❑ Yes El No n. ft. SPOILS gI-2-z : v _ � Contamination Noted: ❑ Yes ❑No 133 _C) =R If yes,spoils storage Location: atoll Rio — l ,.cion Covered: ❑ Yes ❑No = gr-',w If yes, material: rte. :<. GROUTING or DESTRUCTION Total Depth:1�C l� - Depth to Water: --- n• tt' Grout Material: ---1wr MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet ❑Boring Installation� Slot Size: oring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: Gravity ❑Tremie ❑Other: Type of Method: ( Water Cement 471b I Water Cement 941b allons Bas allons Bags Thickest Thinnest 9Bags Thickest Thinnest Bags Bentonite/Cement Mix 3% Mix 5% Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 5 10 1 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 5 25 50 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 a 40 80 s �b bags W/ 12u 9aUanS Wcoy-y 10/16/2017 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s'cehd.com