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- SAN. IOAQUIN Environmental Health Department <br /> 3� —COUNTY - <br /> ��O9t, P� Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: Inspector: CONSTRUCTION <br /> Facility A dre s (�6, SCLvI�[jW• OCLJ1_ W <br /> Well Address: Total Depth: <br /> WP# ' - Well#:_ ,- �- Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: Min 2" Annular EHD Seal Verified: [I Yes El No <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: '` Filter Pack From: To: <br /> Geologist: Bentonite From: To: <br /> 41 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: WT <br /> height <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: COhPLErION COMP=oN <br /> Method: Ground Surtxs <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes El No �ft' <br /> tt. <br /> tt. <br /> SPOILS <br /> = a <br /> Contamination Noted: ❑ Yes El No — <br /> If yes, spoils storage Location: atottod <br /> on — <br /> Covered: ❑ Yes ❑No <br /> g-ve,Pack <br /> If yes, material: s= <br /> GROUTING or DESTRUCTION Total Depth: 2� — <br /> Depth to Water: J� j n• n' <br /> Grout Material: InLiE <br /> Gallons of Grout Used: fln MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation Well Destruction O� ,�Q Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation ❑Boring Destruction �r Bags of Cement: <br /> METHOD USED fir\ Bags Sand/Gravel: <br /> ❑Pressure Grout $Over Drill � Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity ATremi 4—,, ❑Other: Type of Method: <br /> Water Cement 71b Water Cement 941b <br /> allons :a Rs gallons Bags <br /> Thickest Thinnest #Bags Thickest Thinnest #Bags Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94 lb 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 /> 1s 30 6 30 60 6 <br /> 17.5 35 7 35 70 7 <br /> 20 40 8 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 I www.s4cehd.com <br />