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SKJOAQUIN <br /> COUNTY— Environmental Health Department <br /> �9LlP. Greatness grows here. <br /> rr Monitoring Well/Soil Boring Inspection Report <br /> Date: n\P Inspector: w CONSTRUCTION <br /> Facility Address: <br /> Well Address: Total Depth: <br /> WP# Well#: 3 Drilling Rig Type: MMO �D'y()I P-M <br /> Soil Boring#: <br /> Drilling Company: �c.4t,>�. <br /> Min 2"Annular EHD Seal Verified: E] Yes El No <br /> � <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: Filter Pack From: To: <br /> Geologist: Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe []Christie Box <br /> Domestic Well Onsite: ❑ Yes []No casing <br /> If yes, location and distance: height <br /> SAMPLINGasovE-GROUND —QWT <br /> *W <br /> Holding Temperature: COMPLETION CcomPLEnooN <br /> Method: Ci=ndSurtxs "+ —'--'� <br /> Screening Method: grout <br /> 1 <br /> Verified Chain of Custody: ❑ Yes El No <br /> ft. <br /> SPOILS <br /> sR• <br /> Contamination Noted: 1A Yes ❑No — <br /> If yes,spoils storage Location: <br /> saC.on <br /> Covered: ❑ Yes El No — <br /> :k: — growl aacic <br /> If yes, material: <br /> GROUTING or DESTRUCTION'Total Depth: <br /> Depth to Water: <br /> Grout Material: � � MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> ❑Boring Installation Slot Size: <br /> Boring Destruction Bags Size: <br /> Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity *Tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> aflons Bags gallons _ BaRs <br /> Thickest Thinnest t1 Bags Thickest Thinnest xBags 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 Bentonite per 94 Ib 2.82 4.7 <br /> 7.5 15 3 15 1 30 3 <br /> 10 20 4 20 1 40 4 ` <br /> 12.5 25 5 25 50 s <br /> 15 30 6 30 1 60 6 3fG Q SQ�� v� 0 <br /> 17.5 35 7 35 1 70 7 <br /> 20 40 8 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sicehd.com <br />