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U7fy 'o SAN JOAQUIN Environmental Health Department COUNTY Greatness grows herd Monitoring Well/Soil Boring Inspection Report Date: 2 Inspector: "�` CONSTRUCTION Facility Address: c� r C Well Address: Total Depth: WP# �1ab1�f,1 I Well#: Drilling Rig Type: Soil Boring#: tib Min 2" Annular EHD Seal Verified: ❑ Yes 11 No Drilling Company: 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: height SAMPLING ABCVE•GRCYJNp Holding Temperature: COWLETION C� IPLE'nCN Method: G=n°sulac* Screening Method: groat Verified Chain of Custody: ❑ Yes El No �ft. tt. tt. SPOILS . Contamination Noted: ❑ Yes ❑No — If yes, spoils storage Location: sb�d arc:cn Covered: ❑ Yes ❑No = ¢a voi If yes, material: _- GROUTING or DESTRUCTION Total Depth:_ _- Depth to Water: r (j v(� r n — n Grout Material: 2�� C�tw2k1 MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation U$Boring Destruction Bags iz 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 471b Water Cement 941b allons Bags gallons Bags Thickest Thinnest )tBags 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, 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 1 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com