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1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />SAIC,JOAQUIN <br />1.47, COUNTY <br />Greotness grov.s here. <br />Environmental Health Department <br />Monitoring Well/Soil <br />Inspector: Mel, 55i4 ASS: fyy <br />1-10 2f 1-t&eN <br />WP#: <br />Well#: <br />Soil Boring#: Aor1 ewyi <br />Drilling Company: Co I. 10(n; Vu S Tc11 <br />Driller Onsite: C-10,1 1- <br />Consultant: Condue- <br />Geologist: LkA c <br />Public Water System Onsite: fl Yes <br />Domestic Well Onsite: 1E1 Yes <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method: <br />Verified Chain of Custody: <br />SPOILS <br />Contamination Noted: <br />If yes, spoils storage Location: <br />GROUTING or DESTRUCTION Total Depth: <br />Depth to Water: <br />Boring Inspection Report <br />CONSTRUCTION <br />Total Depth: <br />Drilling Rig Type: <br />Min 2" Annular Seal Verified: LII Yes ON° <br />To: <br />To: <br />To: <br />To: <br />From: <br />From: <br />From: <br />From: <br />Screen Length <br />Filter Pack <br />Bentonite <br />Grout <br />COMPLETION LI Stove Pipe El Christie Box <br />casing <br />height <br />Covered: <br />If yes, material: <br />OWell Installation III Well Destruction <br />lilBoring Installation Boring Destruction <br />METHOD USED <br />El Pressure Grout 00ver Drill <br />Gravity 2rTremie DOther: <br />Water <br />gallons <br />Cement 471b <br />Bags <br />Water <br />gallons <br />Cement 94Ib <br />Bags <br />Thickest Thinnest 4Bags Thickest Thinnest # Bags <br />2.5 CO 0 5 10 1 <br />s 10 2 10 20 2 <br />7.5 15 3 15 30 3 <br />10 20 4 20 40 4 <br />12.5 25 5 25 50 5 <br />15 30 6 30 60 6 <br />17.5 35 7 35 70 7 <br />20 40 8 40 80 8 <br />Blank Feet Screen <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 lb 1.41 2.47 <br />Bentonite per 94 lb 2.82 4.7 <br />4 3 <br />Date: <br />Premise Address: ) <br />D Yes ONo <br />Yes LINo <br />LI Yes LI No <br />Grout Material: e rv) e <br />Gallons of Grout Used: MATERIALS/DEVELOPMENT <br />Casing Type: <br />Feet <br />7-