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6TORING WELL INSTALLATION REPOIO <br /> Date: I I 1 CONSTRUCTION <br /> Premise Address: S � Sr Total Depth <br /> Screen Length (from) _(to) <br /> Well No.: ln� l e'1 r I/1 L� Filter Pack (from) 4p�) _(to <br /> Bentonite (from) tJ?il, (to) L'_) <br /> Inspector: Grout (from) ~ � z (to) <br /> Drilling rig type <br /> Permit No. — ���� Auger O.D. 1,a <br /> Completion . Stove pipe/ lu-istie bo (c cle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant �� 1�Y1 � <br /> Geologist <br /> ABOVE-GACUND CHA7STY 80X <br /> COMPLRION COMPLE71CN <br /> SPECIAL PERMIT INFO. Ground S�a1an <br /> Distance to sewer line 7 grout <br /> Domestic well on site -(y/Cn;) _� tt> <br /> If yes, location and distance - <br /> . ft. <br /> ft. <br /> a <br /> C <br /> SAMPLING slonod <br /> sadcn <br /> Holding Temperature IL4 _ g, ,l Pack <br /> Method — <br /> Screening Method ;r <br /> Tracking Sheet • (y/ n ) <br /> ft. — IL <br /> SPOILS <br /> Storage Method )7 d ViIAGiLS MATERIALS/DEVELOPMENT <br /> Contamination Noted - n) <br /> Storage Location ( Casing type' o r _yam <br /> Blank____.l ft. Screen (t ft. <br /> Slot size0/ <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water S Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method 4 1VA _l R Surge Block: - (y <br /> Quantity Installed Discussed with geo�`gtst: - ( y/3 <br /> Type of method <br /> EH 29 29 <br />