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SAN JOAQUIN Environmental Health Department :._ COUNTY ` _.'ti Greatness grows here. Monitoring Well/Soil Boring Inspection Report Date: Inspector: CONSTRUCTION Facility Address: Well Address: Total Depth: WP# VUL\'j� Well#: Drilling Rig Type: Soil Boring#: WN Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Driller Onsite: �— Screen Length From: To: Consultant: (p; S��ceL ( �>��sx�ldJ'� art. Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: height —aw, SAMPLING ABOVE-GROUND ISTY. Holding Temperature: COf"P�ION COOMPt ON Method: Ground surfxs Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No —n. n. n. SPOILS Contamination Noted: ❑ Yes El No m If yes, spoils storage Location: slettpd soon = Covered: ❑ Yes ❑No If yes, material: .%p GROUTING or DESTRUCTION Total Depth: Depth to Water: Grout Material: �).c-� Q MATERIALS/DEVELOPMENT Gallons of Grout Used: Casing Type: ❑Well Installation [�Well Destruction Blank Feet Screen Feet ❑Boring Installation ❑ Slot Size: Boring Destruction Bags Size: Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout []Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity �]Tremie ❑Other: Type of Method: Water Cemen 71 Water Cement 941b gall Baps allons Bags Thickest Thinnest 4 Bags Thickest Thinnest Bags BentOnite/Cement Mix 3% MIX 5% MIX 2.5 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 5 10 2 10 20 2 Bentonite per 94 lb 2.82 4.7 7.5 15 1 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 8 40 80 8 �W \� �� 10/16/2017 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s4cehd.com