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SAN %Z�JQAQUIN Environmental Health Department COUNTY r OQ-mess grc ;Ms here . Monitoring Well /Soil Boring Inspection Report Date : ` Z Z Inspector : CONSTRUCTION Facility Address : 5116 C Ie �cfev LCA Well Address : Total Depth : WP # 00 j WS Well # : Drilling Rig Type : Soil Boring# : —13 ILMin 2 -' Annular EHD Seal Verified : ❑ Yes ❑ No Drilling Company : Driller Onsite : Screen Length From : To : Consultant : Filter Pack From : To . 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 : hs3ght SAMPLING . � p Holding Temperature : COMPLETION oVMPsiON Method : Screening Method : grout Verified Chain of Custody : ❑ Yes ❑ No ft' ft. SPOILS Contamination Noted : ❑ Yes ❑ No rir If yes, spoils storage Location : ss�cn i; Covered : ❑ Yes El No VAVW Pack _. If yes , material . GROUTING - or- DESTRUCTION . Total Depth : . -�f - . .: . .: Depth to Water : ft. Grout Material : I✓ eeoo. CON d Gallons of Grout Used : S U �r� G MATERIALS / DEVELOPMENT Casing Type : ❑ Well Installation ❑ Well Destruction Blank Feet Screen Feet Slot Size : El Boring Installation Eoring Destruction Bags of Cement : METHOD USED Bags Sand/Gravel : ❑ Pressure Grout ❑ Over Drill Type/ Brand of Bentonite : Filter Pack Type/Size . ❑ Gravity ?[ remie ❑ Other : Type of Method : Water Cement 471b Water Cement 941b allons Bas gallons Bags Thickest Thinnest ;` Rags Thickest Thinnest "I Rags 3 55 1 ;e( 5 M X 2, 5 5 1 5 10 1 Bentonite per 47 lb -I . 41 2047 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 S 11 40 1 80 8 10/ 16/2017 1868 E . Hazelton Avenue J Stockton , California 95205 T 209 ' 468- 3420 J F 209 464- 0138 - 1 www . sicehd . com