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MONI1�uRING WELL INSTALLATION REPORT �,w► <br /> CONSTRUCTt ON <br /> Date: f'/ <br /> �!'2�1�G Iw�' Total Depth <br /> la o <br /> Premise Address: Screen Length <br /> Well No.: /!'IG��d (v h�Gt/t d 7 Filter Pack (from) (to) <br /> G J <br /> Bentonite (from) <br /> Grout (from) (to) <br /> r: — <br /> Inspecto . � <br /> Drilling rig type <br /> Auger O.D. _r_ I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: height <br /> Consultant <br /> /J y 6 <br /> Geologist /'� G�u� A3CYE-G8CUND y 3OX <br /> TS' tJ�I COMPLETION COMPLETICN <br /> Ground Suiacs <br /> SPECIAL PERMIT INFO. <br /> � grout <br /> Distance to sewer line <br /> Domestic well on site - (y/P `hW f p -7 ft. <br /> If yes, location and distance - ft. <br /> m <br /> Mora.•! c <br /> SAMPLING �a iacdcn <br /> ala _ Y <br /> Holding Temperature 7 d Pack <br /> Method <br /> Screenin;MethodSU _ <br /> Tracking Sheet - ( n ) <br /> VO Ir <br /> SPOILS <br /> Storage Method G+, 1 Ltd/ � MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/6)- <br /> a Location ay.-• �� / - Casing type <br /> Stora wG <br /> g Blank ft. Screen R• <br /> Slot size /l/J <br /> GROUTING Bags cement <br /> Buckets bentonite / <br /> DDepth Bags sand/gravel — <br /> Depth to wateFilter Pack type/size <br /> Mix Ratios <br /> Installation Method -sz= Surge Block: - ( y/ �1 167 �� lJ <br /> Quantity Installed N D Discussed with geologt . O/ n ) <br /> Type of method <br /> EH 29 29 <br /> __-- V <br />