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SANJOAQUIN <br /> Environmental Health Department <br /> --COUNTY- <br /> Greatness grows here <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date:�I Inspectors 1 CONSTRUCTION <br /> Facility Address: r—O <br /> Well Address: Total Depth: <br /> WP# a Well#: Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: n 2"Annular EHD Seal Verified: ❑ Yes ❑No <br /> Driller Onsite: Green Length From: To: <br /> Consultant: �J � Filter Pack From: To: <br /> Geologist: S /%e up'_ Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes El No casing <br /> If yes, location and distance: height <br /> WT —QW7:F <br /> SAMPLING ABOVE-GROUND __ <br /> Holding Temperature: COMPLETION COMPt.E'rION <br /> Method: Ground Sul"' <br /> Screening Method: groLA <br /> Verified Chain of Custody: ❑ Yes El No •i---n• <br /> ft. <br /> tt. <br /> SPOILS = <br /> — - m <br /> Contamination Noted: ❑ Yes El No — <br /> If yes,spoils storage Location: stood <br /> on <br /> Covered: ❑ Yes ❑No <br /> If yes, material: � <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: n tt. <br /> Grout Material: <br /> Gallons of Grout Used: n Q MATERIALS/DEVELOPMENT <br /> Cj <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> []Boring InstallatiolB,oring Destruction Bags of Cement: <br /> METHOD USED _ Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> L ravity ❑Tremie ❑Other: Type of Method: <br /> 1 Water Cement 471b Water Cemen 941b <br /> allons Bas allons Ba <br /> Thickest Thinnest xBags Thickest Thinnest MB 17 <br /> 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 /> 20 40 8 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />