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$ANJOAQUIN Environmental Health Department --COUNTY— ,,., Greotness grows here. Monitoring Well/Soil Boring Inspection Report Date: Inspector: CONSTRUCTION Facility Address: Well Address: Total Depth: WP# ?mbo ICA Well#: Drilling Rig Type: Soil Boring#: Drilling Company: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Driller Onsite: Screen Length From: To: Consultant: 1 Filter Pack From: To: l Geologist: 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: � height: SAMPLING ABOVE-GROUND IO Holding Temperature: CONPLFTION COMPLETION Method: Qmnd su lan Screening Method: Grout Verified Chain of Custody: ❑ Yes ❑No �tt• n. SPOILS e Contamination Noted: ❑ Yes ❑No ° If yes,spoils storage Location: .bnod toc4on Covered: El Yes ❑No gravol Pack If yes, material: GROUTING or DESTRUCTION Total Depth: Depth to Water: Grout Material: QA rP�VtQ.n MATERIALS DEVELOPMENT Gallons of Grout Used: 004LA - - Casing Type: ❑Well Installation ,) Well Destruction Blank Feet Screen Feet ❑Boring Installation ❑Boring Destruction Slot Size: Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: *'ressure Grout ❑Over Drill Filter Pack Type/Size: ❑ Gravity ❑Tremie ❑Other: Type of Method: Water ent 471b Water Cement 941b allons Bags gallons Bags Thickest Thinnest s Thickest Thinnest 4Bags Bentonite/Cement Mix 8%Mix 5%Mlx 2.5 5 11 1 5 to 1 Bentonite per 47 lb 1.41 2.47 5 10 2 10 20 2 Bentonite per 94lb 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 30 6 3o 60 6 17.S 35 7 35 70 7 20 40 8 40 BO 0 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s'cehd.com