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SANvJOAQUIN Environmental Health Department COUNTY Greatness Greatness grows herr Monitoring Well/Soil Boring Inspection Report Date: _ Inspector: CONSTRUCTION Facility Address: ZJSb 1 � Ol►.1 - Well Address: Lj Total Depth: WP# lkZt1IAWell#: Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes El No Drilling Company: Driller Onsite: A Screen Length From: To: Filter Pack From: To: Consultant: Geologist: Bentonite From: To: 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: height SAMPLING ABOVE-GROUND Holding Temperature: COWPLETZN C C#AP=CN Method: Ground Soman Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No �ft. n. n. SPOILS = = e Contamination Noted: ❑ Yes ❑No If yes, spoils storage Location: stoned &action Covered: ❑ Yes ❑No If yes, material: GROUTING or DESTRUCTION Total Depth: \.P% Depth to Water: n' Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation ❑Well Destruction ' Blank Feet Screen Feet Slot Size: El Boring InstallationBoring Destruction- Bags of Cement: METHOD USED Bags Sand/Gravel: ❑ Type/Brand of Bentonite: Pressure Grout ❑Over Drill 1�� Filter Pack Type/Size: ❑ Gravityrrie ❑Other: Type ofu� d _:! Water Cement 47lb Water Cement 94 lb 4'V gallons Bas gallons Bas Thickest Thinnes ttBags Thickest Thinnest Jt Bags Be tonite/Cement Mix 3% Mix 5%Mix 2.5 5 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 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.socehd.com