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SANdOAQUIN <br /> Environmental Health Department <br /> 1 L•1�' .: �� —COUNTY— <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: agIN a Inspector: 4t 5 CONSTRUCTION <br /> Facility Address: I NSF <br /> Well Address: Total Depth: <br /> WP# l pooLi`5V Well#:t Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: Cnl%(Uelnc.0 Min 2"Annular EHD Seal Verified: ElYes El No <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: Filter Pack From: To: <br /> Geologist: <br /> 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 /> SAMPLING ABOVE-GROUND <br /> COMPLETION compLE coMriE BOX <br /> Holding Temperature: rioN <br /> Method: Ground S"la°' <br /> Screening Method: grout <br /> Verified Chain of Custody: ❑ Yes El No �n. <br /> n. <br /> SPOILS <br /> e <br /> Contamination Noted: ❑ Yes ❑No :° = " <br /> If yes,spoils storage Location: slottad <br /> T. <br /> arrc7on S <br /> Covered: ❑ Yes ❑No <br /> If yes,material: <br /> GROUTING or DESTRUCTION Total Depth: to `Ilk <br /> Depth to Water: - -� t., I n• <br /> Grout Material: MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: Casing Type: <br /> ❑Well Installation ❑Well Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation %oring Destruction Bags of Cement: <br /> METHOD USED Bags Sand/Gravel: <br /> Type/Brand of Bentonite: <br /> ❑Pressure Grout Dover Drill <br /> Filter Pack Type/Size: <br /> Gravity ❑Tremie ❑Other: Type of Method: <br /> Water erit 471b Water cement 941b <br /> m <br /> allons Ba s gallons Bags _ <br /> Thickest Thinnest #Ba Thickest Thinnest #Bags _ Bentanitel %Ml Cement Mix 3% MIX 5X <br /> 2.5 5 1 5 10 1 Bentonite or <br /> 47 Ib 1.41 2.47 <br /> 5 102 10 20 2 <br /> 7.5 15 3 15 30 3 Bentonite per 94lb 2.82 4.7 <br /> 15 - <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 0 40 80 3 <br /> 10/16/2017 <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.s'cehd.com <br />