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PcuiN c, SANJOAQUIN Environmental Health Department —COUNTY- �c,� r/ Greotness grows here Monitoring Well/Soil Boring Inspection Report Date: Inspector:' �a 4. CONSTRUCTION Facility Address: . W, j9iene Well Address: RwaA4 o X- 5f 4/le- Total Depth: WP#QQ g3 Well#: O$ 11 Drilling Rig Type: Soil Boring#: S& c� Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: P t^ Driller Onsite: Screen Length From: To: Consultant: ( o4-4I Filter Pack From: To: Geologist: *{ti Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: IffT height SAMPLING ABOVE-GROUND Holding Temperature: COWLErlON COMPLETION Method: Ground Surface Screening Method: Grout Verified Chain of Custody: ❑ Yes El No tt. ft. SPOILS a Contamination Noted: ❑ Yes ❑No >" If yes,spoils storage Location: slotted sac ion Covered: ❑ Yes ❑No = �s If yes, material: S �j �„ GROUTING or DESTRUCTION Total Depth: Depth to Water: n• n' Grout Material: y-`� MATERIALS/DEVELOPMENT Gallons of Grout Used: ^-�J O �[ Casing Type: ❑Well Installation � Well Destruction Blank Feet Screen Feet / Slot Size: ❑Boring Installation ❑Boring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout Over Drill Filter Pack Type/Size: ElGravity +remie ther: Type of Method: Water Cemen 7Ib Water Cement 941b allons S. allons Bags Thickest Thinnest JtBags 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 8 40 80 8 5 1S 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sucehd.com