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SALAAM,, Environmental Health Department — COUNTY— ,\ Greatness grows here. �i i Monitoring Well/Soil Boring Inspection Report Date: a �I l InspectorC W 6 e%^ CONSTRUCTION Facility Address: ✓ OlAe Well Address: ��(m Total Depth: 3© CPT Wp# ell#: Tj Drilling Rig Type: �1 Soil Boring#: � t Min 2"Annular EHD Seal Verified: ❑Yes ❑No Drilling Company: Driller Onsite: Screen Length From: To: Consultant: K / Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes 1INo COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes WNo caging If yes, location and distance: � height SAMPLING ABOVE-GROUND y�x Holding Temperature: corw�rloN COMPLETION Method: O otina s +----- Screening Method: grout Verified Chain of Custody: ❑ Yes [-]No n' ft. SPOILS yy Contamination Noted: ❑ Yes ❑No If yes,spoils storage Location: 4b� s�etlon _ Covered: ❑Yes ❑No If yes,material: GROUTING or DESTRU ION P Tot Dept d A De th to Water: b 3 S e � Grout Material: Gallons of Grout Used: MATERIALS/DEVELOPMENT �tton yy wp Casing Type: ❑Well Installation ❑WeII DBstr c ion �1 �I. Blank Feet Screen Feet f�-f Slot Size: ❑Boring Installation$Boring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: ❑ Gravity j<remie ❑Other: Type of Method: Water Cement 4716 Water Cement 941h allons se gallons Bags Thickest hlnnest 7lBags Thickest Thinnest Bags Bentonite/Cement Mix 3% Mix 5%Mix 2.s 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 s io 2 10 io 2 Bentonite per 94 lb 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 2 50 15 30 6 30 60 6 17.5 35 7 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.sicehd.com