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SAN_JOA UIN _ Q Environmental Health Department —COUNTY— Greatness grows here. / Monitoring Well/Soil Boring Inspection Report Date: (7 � 2'�oinspector. t1r'j'i A CONSTRUCTION Facility Address: Well Address:Z0 6O &vjy S-f. Total Depth: _ RSA C WP# 0 0 L1 0 `ti 5 Well#: M W- Drilling Rig Type: C7 J A Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company S �1 ✓t yid Driller Onsite: Screen Length From: To: Consultant: VPvI U, :T:Ke_ . Filter Pack From: To: Geologist: K Bentonite From: To: Grout From: To: Public Water System Onsite: ❑Yes ❑No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑Yes ❑No casing If yes,location and distance: I height SAMPLING ABOVE-GROUND cHRm-rr-Box Holding Temperature: CONFLEMN con+rt-ErioN Method: °randsulacs _F- Screening Method: grout Verified Chain of Custody: ❑ Yes []No ft. ft. SPOILS ft Contamination Noted: ❑ Yes ❑No If yes,spoils storage Location: •toned radon ? ! _ Covered: ❑ Yes ❑No = ¢,,,,tom If yes,material: GROUTING or DESTRUCTION rrT tal Depth:�� Depth to Water: Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: f — Q 4T Casing Type: ❑Well Installation Well Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation ❑Boring Destruction Bags of Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity FUrTremie ❑Other: Type of Method: Water Cement 471b Water Cemen 411, ailons eggs eallons Ba _ %2.47 Thickest Thinnest 4Bags Thickest Thinnest kBags Bentonite/Cement Mix 3% Mixa5 5 1 5 10 1 Bentonite er 47 Ib 1.415 10 2 10 20 2 Bentonite per 94lb 2.82 7.5 1s 3 is 30 3 - 10 20 4 20 40 4 12.5 25 5 25 50 5 35 30 6 30 60 6 17.5 35 7 35 70 7 20 40 3 40 30 3 ^AQ /J Vl 2 bay S 10/16/2017 1868 E. Hazelton Avenue I Stockton, alifornia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com