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1 <br /> ;•UySANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspector: CONSTRUCTION <br /> Facility Address: <br /> Well Address: Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes El No <br /> Drilling Company: <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 /> SAMPLING AWvE-dRoutao . <br /> )� <br /> Holding Temperature: cowPLETION ErioN <br /> Method: Ground SLida" <br /> Screening Method: M grout <br /> Verified Chain of Custody: ❑ Yes ❑No n- <br /> ft. <br /> SPOILS <br /> Contamination Noted: ❑ Yes ❑No <br /> If yes,spoils storage Location: — <br /> sfottai >r -- <br /> sac'.an <br /> Covered: ❑Yes ❑No9-01'' = r <br /> ack <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: - JL <br /> GroutMaterial: (?Q1" C1 rneo <br /> MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: <br /> Casing Type: <br /> ❑Well Installation []Well Destruction Blank Feet Screen Feet <br /> ❑ Slot Size: <br /> Boring Installation Destruction Bags Size: <br /> Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> ❑ Gravity Wremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> gall s Bas gall ons Bags <br /> Thickest Thinnest riBags Thickest Thinnest #Bags 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 30 3 ; <br /> 10 20 4 20 40 4 <br /> 12.5 25 5 25 50 5 C� <br /> 15 3o 6 30 60 6 /4 <br /> 17.5 35 7 35 70 7 `f <br /> 20 40 8 40 80 8 <br /> 55 a` �M W �iM 10/16/2017 <br /> C3 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />