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"_ ... ��NITORJNG WELL INSTALLATIONJ�REPOi ' <br /> t i SEE <br /> Date: <br /> i0• S CP ' {a ' CONSTRUCTION <br /> Premise Address: ( U 'by/De6w�_ _ Total Depth 90 <br /> �— Screen Length (from) 9_12 _jto)_��' <br /> Well No. w Filter Pack (from) an (to) f <br /> Bentonite ;i (from) (to) Sb <br /> Inspector: mpplxfJ Grout (from) (to <br /> ---- - Drilling rig ty' pe <br /> Z ,� CI t i <br /> Permit No. 4 � Auger.1O.D. i1. 1o1f1.6. <br /> t31r CompI,etion "Stove pipe/ i—nstie x circle one) <br /> Drilling Company: <br /> Driller* wca\ GJL� M casing <br /> • � <br /> height } <br /> Consultant 3 <br /> �II <br /> E) <br /> 41 <br /> - 6 ' <br /> Geologist <br /> -GRCUN <br /> 1180{/E D Q-iR*i(_80X Y <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. iM Ground Surfaca <br /> .. P <br /> Distance to sewer line r s <br /> grout <br /> Domestic well on site - (y/ n :E <br /> If yes, location and distance - <br /> eft. ft- f <br /> j SAMPLING _ o <br /> E seacn — <br /> Holding Temperature � 0 c�,� h � qMvW pack � <br /> Method <br /> Screenin;Method V1 a t � t <br /> Tracking Sheet - {y/ n ) { <br /> Z: <br /> SPOILS ; <br /> �4 <br /> Storage Metho A� rD5 cica MATERIALS,_fDEVE[,4PMENT <br /> Contamination Noted - <br /> Storage Location y/ n) <br /> _ Casing,,type i 2 C- <br /> ®� <br /> Blank,1 &s ft. Screen -2.5 ft. <br /> t` 5cod' Slot sic it (2-2O <br /> GROUTING r �J� Bags cement:` <br /> 11ZBuckets bentonite 1 .DWW <br /> Depth to water �_ CO - Bags sand/gravel_ 13 bk' <br /> Mix Ratios _ Filter Pack type/size 3 <br /> Installation Method finCw+.rA%A� 50' Surge Block:' (y n <br /> Quantity Installed Discussed with geo ogist: - y n) <br /> Type of method <br /> EH 29 29 „9 <br /> I - F <br /> W <br /> ��l�i lal6�y3 �2Gu/— <br />