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Q MONITORING WjrNrTION I "stT <br /> Z- <br /> �s� <br /> S�41 <br /> Date: <br /> U 1 Z CONSTRUCTION <br /> �, "" � � t <br /> Premise Address: �P� Total Depth, �� <br /> F Seen L (from} (to) <br /> Well No.: Filter P (from) (to) <br /> ` O Ben to (fro (to <br /> ut AOM) (t ) <br /> !nspector. d rifling rig type ,d <br /> {t' Auger' OD. ID. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company. <br /> `� Casia <br /> Driller: height <br /> AC-ai <br /> Consultant„ __ t 1 <br /> Geologist_ Gi�u ABCYEwi�OUND FW- <br /> a-p*—, -aOX <br /> CC&F R10N �{r{p1=1 JCN <br /> ��Su'f�cs , <br /> SPECIAL PERNfET INFO- •sewer , <br /> � <br /> Distance to sewer line z <br /> y - <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - <br /> (g . - Cald��� — • <br /> S4 <br /> :1on2d <br /> S, AM LING wcicn 3 <br /> Holding Tempera=efl <br /> Method — <br /> Screening Method —_ <br /> racking Sheet - C Y/ n ) <br /> 7 ft. — M <br /> SPOILS �7 f/„ <br /> Storage Method MATE����I'OPI <br /> VIENT <br /> Contamination Noted - (� n } 5 <br /> Casing type �. <br /> Storage Location Blank f;. Seen <br /> Slot size <br /> GROUTINGBags cement <br /> Buckets bentonite <br /> (, Bags sand/gravel <br /> Depth to water Filter Pack we/size <br /> Mix Ratios Surge Block: - C y/ n ) <br /> installation Method Discussed with geologist: - (Y/ n) <br /> Quantity Installed Type of method <br /> EH 2929 rC <br /> { <br /> l W <br />