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SAN JOAQUIN Environmental Health Department -- COUNTY- . \JI«tr il;0i gror;s i,Cre. Monitoring Well/Soil Boring Inspection Report Date:._6] ai wo Inspector: 1�V ( CONSTRUCTION Facility A dress "`� �J• I; Well Address: _ Total Depth: WP# U.0 1"M Well#: 11bz13�)y� 15 Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Driller Onsite: f Screen Length From: To: Consultant: L, Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑Yes El No COMPLETION ❑ Stove Pipe El Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes,location and distance: height SAMPLING ABOVE-GROUND CowPLET1oN C-HRI Y-Sox Holding Temperature: COMPLETION Method: Ground Sumac. Screening Method: groat Verified Chain of Custody: ❑ Yes ❑No ft. ts. n. SPOILS , v'� o Contamination Noted: ❑Yes ❑No r� If yes,spoils storage Location: sac5on � — Covered: ❑ Yes ❑No G—VI P-ack If yes, material: = .. -48' GROUTING or DESTRUCTION Total Depth: J aJ =_ Depth to Water: — n Grout Material: -IK)tit Lko I ✓MATERIALS/DEVELOPMENT Gallons of Grout Used: 2 `� Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet ❑Boring Installation ❑ Slot Size: Boring Destruction Bags Size: Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity ❑Tremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b Ilons Ba R@11111ons Bags Thickest Thinnest #Bags Thickest Thinnest #Bags Bentonite/Cement Mix 3%Mix 5%Mix 2.5 5 1 5 10 1 Bentonite per 47 Ib 1.41 2.47 s 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 25 50 5 15 30 6 30 1 60 6 17.5 35 7 35 1 70 7 20 40 8 40 1 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