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SAKJOAQUIN <br /> Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <br /> Monitoring Well/Soil Boring Inspection Report <br /> Date: ` Inspect r: cq CONSTRUCTION <br /> Facility Address: 3 1 j y <br /> Well Address: 2-3' .5 " i Total Depth: <br /> WP# O o L400 Well#: J? S l� Drilling Rig Type: <br /> Soil Boring#: <br /> Drilling Company: iLAJ S Min 2"Annular EHD Seal Verified: ❑ Yes El No <br /> Driller Onsite: Screen Length From: To: <br /> Consultant: C Filter Pack From: To: <br /> Geologist: �., y Bentonite From: To: <br /> Grout From: To: <br /> Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box <br /> Domestic Well Onsite: ❑ Yes ❑No casing <br /> If yes, location and distance: height <br /> iff <br /> W ff- <br /> SAMPLING ABOVE-GROUND <br /> Holding Temperature: CPLETION compLenoN <br /> OM <br /> Method: oroundSLOace 7— <br /> Screening Method: trout <br /> Verified Chain of Custody: ❑ Yes ❑No ft. <br /> tt. <br /> SPOILS <br /> xR s <br /> Contamination Noted: ❑ Yes []No <br /> If yes, spoils storage Location: <br /> sfonad <br /> sac-jon <br /> Covered: ❑ Yes El Nogmv*1 pack <br /> If yes, material: _ <br /> GROUTING or DESTRUCTION Total Depth:�(� .. <br /> Depth to Water: N� { P.+�(c-. �y�_ ft• — n <br /> Grout Material CPA"� MATERIALS/DEVELOPMENT <br /> Gallons of Grout Used: ;;2 Casing Type: <br /> ❑Well Installation #ell Destruction Blank Feet Screen Feet <br /> Slot Size: <br /> ❑Boring Installation ❑Boring Destruction Bags iz Cement: <br /> METHOD USED p Bags Sand/Gravel: <br /> 5✓N ' at Type/Brand of Bentonite: <br /> ressure Grout 4ver Drill uAa W.0 Filter Pack Type/Size: <br /> [Gravity ❑Tremie ❑Other: (44;e sW Type of Method: <br /> h <br /> Water Cement 471b Water Cement 4lb <br /> allons Bags gallons Bags <br /> Thickest Thinnest #Bags Thickest Thinnest #Baas Bentonite/Cement Mix 3% Mix 5% Mix <br /> 2.5 5 1 5 10 1 Bentonite per 47 lb 1.41 2.47 <br /> 5 10 2 10 20 2 Bentonite per 94 lb 2.82 4.7 <br /> 7.5 15 3 15 30 3 <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 8 40 80 8 <br /> O D 10/16/2017 <br /> 1868 E. HazelUn Avenue Stockton, Walifornia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />