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:,. SAW IOAQUIN Environmental Health Department <br /> —COU NTY— <br /> Gr*(i(Itftei.i jro Pis hcrc. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: ? IS Inspector: 1 CONSTRUCTION <br /> Facility Address: 'M N. f <br /> Well Address: Total Depth: <br /> WP# 75=i'q Well#: D,r'oIing Rig Type: <br /> Soil Boring#: �jp�7�n�S• <br /> Min 2"Annur EHD Seal Verified: ❑Yes ❑No <br /> Drilling Company: Screen Length From: To: <br /> Driller Onsite: <br /> Consultant: Filter Pack From: To: <br /> Geologist: h io Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑Yes [I No COMPLETION ❑Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes El No casing <br /> If yes,location and distance: height <br /> SAMPLING ASOVE-6ROUND cttrilsrt aox <br /> Holding Temperature: COMPLETION COMPLETioN <br /> Method: Gownd Surfx. <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑Yes ❑No tt• <br /> ft. <br /> -ft. <br /> SPOILS k: <br /> Contamination Noted: ❑Yes El No r r r <br /> If yes,spoils storage Location: <br /> wcdon x — <br /> Covered: ❑ Yes ❑No <br /> If yes,material: <br /> GROUTING or DESTRUCTION Total Depth: Lev bgrIn15 <br /> Depth to Water: U)• <br /> Grout Material: <br /> Gallons of Grout Used: ti •*✓ MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> El Boring Installation Woring Destruction Bags iz Cement: <br /> METHOD USED ►✓a Bags Sand/Gravel: <br /> /., 1° Type/Brand of Bentonite: <br /> ❑Pressure Grout ❑Over Drill •�.b Filter Pack Type/Size: <br /> Gravity ❑Tremie ❑Other: Type of Method: <br /> Water ment471b Water Cement 941b <br /> allons Ba eallons Bags <br /> Thickest Thinnest #Bags Thickest Thinnest #Bags Bentonite/Cement Mix 3%Mix 5%Mix <br /> 2.5 5 1 ✓ 5 10 1 Bentonite per 47 Ib 1.411 2.47 <br /> 5 10 2;7 10 20 2 Bentonite per 94 Ib 2.821 4.7 <br /> 7.5 15 3 15 30 3 <br /> 10 10 4 {/ 20 40 4 <br /> 12.5 25 5 ✓• 25 50 5 <br /> 15 30 6 U/ 30 60 6 <br /> 17.5 35 7 ✓ 35 70 7 <br /> 20 40 8 40 80 8 <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.sicehd.com <br />