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WITORING WELL INSTALLATION REPO* <br /> CIV <br /> NSTRUCTION <br /> Date: ` <br /> l T al Depth (to) y <br /> Premise ess: \ Green Length (from) <br /> ilter Pack (from) (CO) 1 <br /> Well No.: N1 � w� Bentonite (from) I _([o) D- <br /> ✓ Grout ( om) = '_ (to) <br /> Inspector. <br /> Drilling rig type <br /> IS 1 IS Auger O.D. —_ I.D. <br /> Permit No. \\ Completion - Stove pipc/clutstie box (circle one) <br /> Drilling Company: W <br /> casing <br /> Driller. 1 � F height <br /> Consultant L��� n7 V <br /> Geologist s ABCvE•GRCUND CHRZTY-BOX <br /> CCAFLETICN CCMPL–c nW <br /> Ground Salads <br /> SPECIAL PERMIT INFO. <br /> proof <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) fL <br /> if yes, location and distance - tt- <br /> J' T SAMPLINHolding TemperatureMethodScreenin;MethodTracking Sheet - (y/ nM <br /> SPOILS <br /> Storage Method 1 i nt a �K� MATFRIALS E�LOPMENT <br /> I <br /> Contamination Notedt yrs ^ casing e <br /> Srorage Location (_+� Bla ft. Screen ft. <br /> Slot size <br /> GTING Bags cement <br /> ROU <br /> I Buckets bentonite D <br /> 3C�_ Bags sand/gravel Y <br /> Depth [o water Filter Pack type/size L� 1C <br /> Mix Ratios Surge Block: - (Y, tl' <br /> installation M dDiscussed with geologist: - ( y/ n ) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />