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SAN J OAQ U I N Environmental Health Department COUNTY Gicutness OUNTYGreu[ness grows here. / Monitoring Well/Soil Boring Inspection Report Date: �! 1 1jq Inspector: ` 19_17 c� A ' CONSTRUCTION Facility Address: II Well Address: [S S11 �c d Total Depth: S5 WP# fib3 y V Well#: Drilling Rig Type: Soil Boring#: Company: Min 2" Annular EHD Seal Verified: C�Yes ❑No Drilling Driller Onsite: `/ 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: 111 height SAMPLING ABOVE-GROUND __ Holding Temperature: COMPLETION COMPLETION Method: Gmnd Sumacs Screening Method: Q.out Verified Chain of Custody: ❑ Yes El No —' o ft. ft. SPOILS o Contamination Noted: ❑ Yes El No If yes, spoils storage Location: abttad ' on r — 3 Covered: ❑ Yes ❑No If yes, material: M< GROUTING or DESTRUCTION Total Depth: �� Depth to Water: Grout Material: t*-1 MATERIALS/DEVELOPMENT Gallons of Grout Used: 3(� G� w> Casing Type: YWell 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: Type of Method: Water Cement 47 lb Water Cement 941b allons Bas gallons Bags Thickest Thinnest l:Bags Thickest Thinnest uBags Bentonite/Cement Mix 3% Mix 3%Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 s 10 z 10 20 z Bentonite per 94 Ib 2.82 4.7 7.5 15 3 15 30 3 s s 25 so s I S6 O6 /Qct vat 2 N bjs 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 a 40 so s � 3 � �� O�WA �'' 10/16/2017 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sicehd.com