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SAN 10AQUIN Environmental Health Department COUNTY 2 .SZ to Monitoring Well/Soil Boring Inspection Report Date: Inspector: ' \VWS CONSTRUCTION Facility Address:' Y ind �11C' SI'• Well Address: Total Depth: WP# DO Z Well#: Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Driller Onsite: Consultant: Q ' Screen Length From: To: o � �,_ Filter Pack From: To: (L� Geologist: 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: height SAMPLING ABOVE-GROUND Holding Temperature: COWPLETION CCMPLEncN Method: Ground Surfaas Screening Method: grart Verified Chain of Custody: ❑ Yes []No �ft' ft. SPOILS 0 Contamination Noted: ❑ Yes KNo — If yes, spoils storage Location: alonod soon Covered: ❑ Yes ❑No If yes, material:OQb m S GROUTING or DESTRUCTION Total Depth: Depth to Water: n IF n' Grout Material: Gallons of Grout Used: MATERIALS/DEVELOPMENT Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation Boring Destruction Bags iz Cement: METHOD USED ' �\ Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill I Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity X-rremie ❑Other: / Type of Method: Water Cement 471b Water Cement 94 lb allons Bas gallons Bags Thickest Thinnest ttBags Thickest Thinnest J?Bags Bentonite/Cement Mix 3% Mix 5% Mix 2.5 5 1 ✓ 5 10 1 Bentonite per 47 Ib 1.41 2.47 s 10 2 r 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 10/16/2017 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com