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:,. S A N.J O AQ U l N Environmental Health Department —COUNTY-- GreuGtesi jiows flere. Monitoring Well/Soil Boring Inspection Report Date: C'Inbj. Inspector: CONSTRUCTION Facility A dress: b S. Well Address: Total Depth: WP#_ lbob V Well#: _"kVS Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: ❑Yes ❑No Drilling Company: CtA) Driller Onsite: 0 Screen Length From: To: Consultant: Filter Pack From: To: Geologist: �C�(�,' 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 COkfPLETION CNRI5iY-HOX Holding Temperature: COMPLETION Method: G=nd Sumac. Screening Method: grout Verified Chain of Custody: ❑Yes ❑No ft n. SPOILS Contamination Noted: ❑Yes ❑No If yes,spoils storage Location: sacdon —= Covered: ❑Yes ❑No - ack If yes,material: GROUTING or DESTRUCTION Total Depth:_ Depth to Water: _ ft• — n Grout Material L VV V_W\ D� MATERIALS/DEVELOPMENT Gallons of Grout Used: 2 �,!)S Casing Type: ❑Well Installation 19fWell Destruction Blank Feet Screen Feet ❑Boring Installation ❑ 51at Size: Boring Destruction Bags Size: Cement: METHOD USED Bags Sand/Gravel: _ ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity fTremie ❑Other: Type of Method: Water Cement 47lb Water Cement 941b allons Bags allons Bags Thickest Thinnest #Bags Thickest Thinnest #Bags Bentonite/Cement Mix 3% Mix 5%Mix 2.5 5 1 s 10 1 Bentonite per47 Ib 1.41 2.47 5 10 2 10 20 2 Bentonite per 94 lb 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 1 0 5 15 30 6 30 60 6 17.5 35 7 35 70 7 20 40 a 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com