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ObNITORING WELL INSTALLATION REPO <br />Date: n.' <br />Premise Address:7s- 6Y O •V `Q i S reyc k jn, <br />Well No.: Aw go�A5g5 <br />Inspector. 1Wr14'b" <br />Permit No. <br />Drilling Company. <br />Driller: <br />Consultant <br />Geologist &)d.)iC" (707) 33$ SSSS <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site - ( y / n ) <br />If yes, location and distance - <br />SAMPLING <br />Holding Temperature 4/0(:, <br />Method 13A&41) 74 - <br />Screening Method P1 N <br />Tracking Sheet - (�r-/ n ) <br />SPOILS pp <br />Storage Method <br />Contamination Noted - / n A p <br />Storage Location <br />G✓ .C�t <br />GROUTING <br />l <br />Depth to water <br />Mix Ratios ^- r •-• <br />Installation Method <br />Quantity Installedon.� n <br />EH 29 29 <br />CONSTRUCTION <br />Total Depth <br />Screen Length (from) <br />(to) <br />Filter Pack (from)—(to)— <br />from)(to)Bentonite <br />Bentonite(from) <br />(to) <br />Grout (from) <br />(to) <br />Drilling rig type <br />Auger O.D. <br />I.D. <br />Completion - Stove pipe/cluistie box (circle one) <br />casing <br />IT T <br />T/' <br />:. <br />..ABOVFCCMPLEnCN <br />Ground sunx. Is <br />grout <br />ft. <br />n- <br />tt. _ <br />y� 0 <br />— e <br />= O <br />slot -ad = C <br />tOC�en — <br />�� — prawl padt <br />MATERIALS/DEVELOPMENT <br />Casing type <br />Blank ft. Screen ft. <br />Slot size <br />Bags cement <br />Buckets bentonite <br />Bags sand/gravel <br />Filter Pack type/size <br />Surge Block: - ( y / n ) <br />Discussed with geologist: - ( y / n ) <br />Type of method <br />