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SAN 10AQUIN Environmental Health Department --COUNTY--- Monitoring Well/Soil Boring Inspection Report Date: Inspector: :-r CONSTRUCTION Facility Address:--% Well Address:_ ___ Total Depth: WP# Well#: Drilling Rig Type: Soil Boring#: ) •-)=l-V l-�- Min 2"Annular EHD Seal Verified: ❑ Yes []No Drilling Company: Driller Onsite: t nw y G Screen Length From: To: �H n ,� Filter Pack From: To: Consultant: u Bentonite From: To: Geologist: �.r,s��ti, Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: I T height SAMPLING ABOVEGROUND Holding Temperature: COMPLETION ccoomp�t.EnON Method: Ground Surf ac* Screening Method: grout Verified Chain of Custody: ❑ Yes El No �ft' tt. tt. SPOILS = = o Contamination Noted: ❑ Yes El No If yes, spoils storage Location: stoned sac7on — B Covered: ❑ Yes ❑No = gi 1w Pack If yes, material: GROUTING or DESTRUCTION Total Depth: Depth to Water: L7 tt• n' Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: i J.�p Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation CBoring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: ❑ Gravity C�-Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b allons Bas izallons Bags Thickest Thinnest #Bags Thickest Thinnest »Bags Bentonite/Cement Mix 3% Mix 3% 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 j-_7 20 40 4 12.5 25 25 50 5 15 30 30 60 6 1 35 35 70 7 20 40 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.secehd.com