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COUNTY <br />Greatness �rn,�,s 1�er^- <br />Environmental Health Department <br />Monitoring Well/Soil Boring Inspection Report <br />Date: 1 D/ ( ZZ Inspector: <br />Facility Address: � � - <br />Well Addre s: <br />WP# OCA � ��}�� Well#: <br />Soil Boring#: <br />Drilling Company: r✓"w e � <br />Driller Onsite: <br />Consultant: 7 � � �tf '%'�- �- <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 />CONSTRUCTION <br />Total Depth: <br />1�=2 Drilling Rig Type: <br />❑ Yes ❑ No <br />❑ Yes ❑No <br />Verified Chain of Custody: ❑Yes ❑No <br />SPOILS <br />Contamination Noted: �es ❑No <br />If yes, spoils storage Location: 1�'l.•i'�� <br />Covered: Yes ❑ No <br />If yes, material: <br />GROUTING or -DESTRUCTION Total Depth: <br />Depth to Water: <br />Grout Material: <br />Gallons of Grout Used: <br />�Uell Installation ❑Well Destruction <br />❑Boring Installation ❑Boring Destruction <br />METHOD USED <br />❑Pressure Grout ❑Over Drill <br />❑ Gravity envie ❑Other: <br />Water <br />allons <br />Cement 471b <br />Bas <br />5°I° Mix <br />+Dater <br />allons <br />Cement 941b <br />Ba s <br />Thickest <br />Thinnzst <br />�t E+as <br />Bentonite per 94 Ib <br />Thickest <br />Thinnest <br />� Bags <br />2.5 <br />5 <br />1 <br />5 <br />10 <br />1 <br />5 <br />10 <br />2 <br />10 <br />20 <br />2 <br />7.5 <br />15 <br />3 <br />15 <br />30 <br />3 <br />10 <br />20 <br />4 <br />20 <br />40 <br />4 <br />12.5 <br />25 <br />5 <br />25 <br />50 <br />5 <br />15 <br />30 <br />6 <br />30 <br />60 <br />6 <br />17.5 <br />35 <br />7 <br />35 <br />70 <br />7 <br />20 <br />40 <br />8 <br />40 <br />80 <br />8 <br />Min 2" Annular EHD Seal Verified: <br />Screen Length From: �� j <br />Filter Pack <br />Bentonite <br />Grout <br />COMPLETION <br />From:_ <br />From: <br />From: � � <br />❑ Stove Pipe <br />cas i.ng <br />height <br />AF3CaYE-GROUND CNAtStY-80X <br />COMPLETiG1N CG{NPLE7iQN <br />t3round Surfacs <br />proof <br />ft. <br />tt. <br />ft. <br />-: <br />�K jy <br />"�` � C <br />t,. MM,�,��� � tO� <br />�iVi� y'� .(I <br />s:.i• <br />soon - _, <br />,h <br />�:: �" pn►xv?: pack <br />..�::- <br />h, <br />X <br />ft, '� tt. <br />❑ Yes ❑ No <br />To: � U <br />To: � -S <br />To��:,,��-- � <br />•'L�Christie Box <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 <br />Feet <br />BentanitefOement Mix <br />3°f° Mix <br />5°I° Mix <br />Bentonite per 47 Ib <br />1.41 <br />2.47 <br />Bentonite per 94 Ib <br />2.82 <br />4.7 <br />10/16/2017 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjcehd.com <br />