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SANsIOAQUIN Environmental Health Department <br />—COUNTY— <br />Gr-eatness grows here. <br />Monitoring Well/Soil Boring Inspection Report <br />Date: J ��'\ I"nspector: <br />Facility Address: l) �i l (_ hC�I (� tJ AQ <br />Well Address: <br />WP# Well#: <br />Soil Boring#: <br />Drilling Company: <br />Driller Onsite: <br />Consultant: L <br />Geologist: <br />Public Water System Onsite <br />Domestic Well Onsite <br />If yes, location and distance: <br />SAMPLING <br />Holding Temperature: <br />Method: <br />Screening Method:_ <br />Verified Chain of Custody: <br />wnll c <br />Contamination Noted <br />If yes, spoils storage Location: <br />Covered: <br />r'r1MCTRl Ir'TIr1M <br />Total Depth: — <br />Drilling Rig Type: <br />Min 2" Annular EHD Seal Verified <br />Screen Length <br />From <br />Filter Pack <br />From <br />Bentonite <br />From <br />Grout <br />From <br />❑ Yes El No COMPLETION ❑ Stove Pipe <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />❑ Yes ❑No <br />If yes, material: <br />GROUTING or DESTRUCTION Total Depth:_ <br />Depth to Water:`��a <br />Grout Material: <br />Gallons of Grout Used: <br />❑Well Installation ❑Well Destruction <br />❑Boring Installation Boring Destruction <br />METHOD USED <br />El Pressure Grout ❑Over Drill <br />❑ Gravity �Tremie ❑Other: <br />Water <br />gallons <br />Cement 471b <br />Bas <br />Water <br />gallil ons <br />Cement 941b <br />Bags <br />Thickest Thigest <br />#j8a§S <br />Thickest Thinnest <br />#Bags <br />2.5 5 <br />1 <br />5 <br />10 <br />1 <br />5 10 <br />2 <br />10 <br />20 <br />2 <br />7.5 15 <br />3 <br />15 <br />30 <br />3 <br />10 20 <br />4 <br />20 <br />40 <br />4 <br />12.5 25 <br />5 <br />25 <br />50 <br />5 <br />15 30 <br />6 <br />30 <br />60 <br />6 <br />17.5 35 <br />7 <br />35 <br />70 <br />7 <br />20 40 <br />8 <br />40 <br />80 <br />8 <br />❑ Yes ❑No <br />To: <br />To: <br />To: <br />To: <br />❑Christie Box <br />is <br />MATERIALS/DEVELOPMENT <br />Casing Type: <br />Blank Feet <br />Slot Size: <br />Bags of Cement: <br />Bags Sand/Gravel: <br />Type/Brand of Bentonite: <br />Filter Pack Type/Size: <br />Type of Method: <br />Screen Feet <br />Bentonite/Cement Mix 3% Mix 5% Mix <br />Bentonite per 47 Ib 1.41 2.47 <br />Bentonite per 94 Ib 2.82 4.7 <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.s*cehd.com <br />