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SAN JOAQUIN <br /> Environmental Health Department <br /> COUNTY­ <br /> Greatness Greatness grows here. <br /> 7 <br /> Monitoring Well/Soil Boring Inspection Report <br /> l � c <br /> Date: !�� Inspector: CONSTRUCTION <br /> Facility Ad ress. i <br /> Well Address: Total Depth: <br /> WP# U' Well#: Drilling Rig Type: <br /> Soil Boring#: Min 2" Annular EHD Seal Verified: ❑ Yes ❑No <br /> Drilling Company: CU '( l1(G1 <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: Filter Pack From: To: <br /> Geologist: Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes ❑No casing <br /> If yes, location and distance: height <br /> v6T <br /> SAMPLING AEiOVE-GROUND CHR STY-BOX <br /> Holding Temperature: COMPLETION COMPLEnON <br /> Method: Ground Sumacs <br /> Screening Method: V121 grout <br /> Verified Chain of Custody: ❑ Yes El No n• <br /> ft. <br /> ft. <br /> SPOILS _ <br /> Contamination Noted: ❑ Yes ❑No = CD <br /> If yes, spoils storage Location: stood <br /> sacton <br /> Covered: ❑ Yes ❑No = l <br /> adt <br /> If yes, material: ' _ <br /> GROUTING or DESTRUCTION Total Depth: <br /> Depth to Water: ft• _ ft• <br /> Grout Material: MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: Casing Type: <br /> ❑Well Installation J6well Destruction Blank Feet Screen Feet <br /> El Boring Installation ❑ Slot Size: <br /> Boring Destruction Bags Size: <br /> Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: <br /> Filter Pack Type/Size: <br /> .1029 Gravity remie ❑Other: Type of Method: <br /> Water Ce ent 471 Water Cement 941b <br /> allons Bags Railons Bags <br /> Thickest Thinnest ags Thickest Thinnest Bags Bentonite/Cement Mix 3% MIX 5% MIX <br /> 2.5 5 1 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 <br /> 7.5 15 3 15 30 3 <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 8 40 80 8 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 www.sicehd.com <br />