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SAN JO/IQUIN <br /> Environmental Health Department <br /> COUNTY— <br /> `j;_ .�;,t=`> Greatness groins here. <br /> 1- Monitoring Well/Soil Boring Inspection Report <br /> Date: kXIb 'yn/ Inspector: ' �A CONSTRUCTION <br /> Facility Address: (. <br /> Well Address: Total Depth: <br /> WP# fl Well#: Drilling Rig Type: <br /> Soil Boring#: Z — �t DIZ,_Drilling Company Min 2"Annular EHD Seal Verified: El Yes ONO <br /> . <br /> r:.. .. <br /> Driller Onsite: Screen Length From: To: <br />}-- Consultant: Filter Pack From: To: <br /> �� 'C4C.r <br /> Geologist: 1 ZA IL6 Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes h 6,No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes I�1No casing 7 <br /> If yes, location and distance: ""�� height <br /> SAMPLING AWVF-GROUND CtiR15rY BOX <br /> Holding Temperature: CowLE ION COMPLETION <br /> Method: etosinds"rr'o' <br /> Screening Method: ilsilk grout <br /> Verified Chain of Custody: ❑ Yes ONOTt <br /> SPOILS —tt• <br /> Contamination Noted: ❑Yes f�Vo <br /> If yes,spoils storage Location: �Iorad <br /> Covered: El Yes ONO s4c9ongmw Pack <br /> If yes, material: <br /> GROUTING or DESTRUCTION Total Depth:I D = .. <br /> Depth to Water: <br /> Grout Material:' . ellffoltc <br /> Gallons of Grout Used: MATERIALS/DEVELOPMENT <br /> Casing Type: <br /> ❑Well Installation [Well Destruction Blank Feet Screen Feet <br /> ❑Boring Installation ❑Boring Destruction Slot Size: <br /> Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> ❑ Gravity ❑Tremie ❑Other: Type of Method: <br /> Water Cement 471b Water Cement 9411) <br /> srallons Bags 2allons Baas <br /> TbidalL Thinnest 0Ba s Thickest Thinnest usaas _ BentonitelCennent Mix 3% Mix 15Z. MIX <br /> s 5 s 10 1 Bentonite per471b 1.41 2.47 <br /> 10 2 10 20 2 Bentonite er 941b 2.82 4.7 <br /> 7.5 15 3 15 30 3 -i <br /> 10 20 4 20 40 4 <br /> 12.5 25 5 25 50 5 <br /> 15 30 6 30 60 6 <br /> 17.5 35 7 35 70 7 <br /> 20 40 3 40 30 3 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 I www.sicehd.com <br />