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SAN,,JOAQUIN <br /> -i Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: \��a `�� Inspector: CONSTRUCTION <br /> Facility Address: <br /> Well Address: Total Depth: <br /> WP# Well#: Drilling Rig Type: <br /> Soil Boring#: YIZY.. (1, S <br /> Drilling Company: ��,�a� Min 2"Annular EHD Seal Verified: El Yes ❑No <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 t�No casing <br /> If yes, location and distance: height <br /> SAMPLING N i,\ —CWTABOVE-GROUND <br /> C <br /> Holding Temperature: COWLETION OMPcN <br /> Method: G=nd Sufacs'�.�"" <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes El No ft. <br /> ft. <br /> SPOILS p� � <br /> 0 <br /> Contamination Noted: ❑ Yes YNo <br /> If yes, spoils storage Location: si'onad <br /> ssc9on <br /> Covered: ❑ Yes []No <br /> g—W Pack <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth:�� . <br /> Depth to Water: —M n- <br /> Grout Material: <br /> Gallons of Grout Used: 5S MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> El Boring Installation Boring Destruction Bags iz Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: <br /> ❑ Gravity 'tkTremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 941b <br /> gallons Bas gallons Bags <br /> Thickest Thinnest tlBags 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 <br /> 15 30 6 30 60 6 <br /> 17.5 35 7 35 70 7 <br /> 2D 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />