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'CUI V w SANJOAQUIN Environmental Health Department —COUNTY— `'yr. Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date:' �ti � Inspector: Q.sx'0'A CONSTRUCTION Facility Address: Well Address: Total Depth: WP# Well#:�i �_ Drilling Rig Type: Soil Boring#:_�9� �• �' d Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: DrillerOnsite: �o�� Screen Length From: To: Consultant: Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes EN COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes kN0 casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: CONFLErlON COMPLETION Method: Ground Sudacs T Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No it. ft. ft. _ SPOILS ti 6P i . Contamination Noted: ❑ Yes I1No r: If yes, spoils storage Location: slatted Z;; **=n '— 3 Covered: ❑ Yes ❑No s� — gavot pack If yes, material: . GROUTING or DESTRUCTION Total Depth: -1 Depth to Water: Grout Material: Gallons of Grout Used: MATERIALS/DEVELOPMENT Casing Type: []Well Installation ❑Well Destruction Blank Feet Screen Feet Slat Size: ❑Boring Installation 9Boring Destruction gags iz Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity '�Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b gallons Bas gallons Bags Thickest Thinnest ttBags 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 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com