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Y£MONITORTI <br /> ING WkI 1NST ON REPORT <br /> Date• � � G D <br /> ` CONSTRUCTION <br /> . L L ` Total Depth � <br /> Premise Address: y -� �- — Screen Length (from) (to) <br /> -Filter Pack (from) (to) � <br /> Well No.: T Bentonite (from) (to) 1 <br /> Grout (froth) (to) ---- <br /> Inspector. Drilling rig type <br /> Auger O.D. <br /> I.D. ' a. <br /> Permit No. Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: <br /> • casing <br /> Driller: _ he?ght <br /> .Consultant <br /> Geologist IVF-GRCUND CIHR� Y-3AX <br /> `• 'COh�L`�CfON; CCmpL—MCN <br /> '� �Y C3cticst�d SLs•fxs <br /> SPECIAL PERMIT . <br /> _ INFO � J <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) ,� <br /> if yes, location and distance - -4 -ft. JL <br /> , 4'. , <br /> • aforai 'y+ � l <br /> SAMpLjNG V1V'9 Pack <br /> Holding Temperature <br /> Method <br /> Screening Method - r . <br /> Tracking Sheet - C y/ n) <br /> L,C'-f)i <br /> sP ILS . . Y '. <br /> MATERI AIS/DEVELOPMENT <br /> Storage Method r ,l <br /> Contamination Noted - (y/ n) Casing type ft. <br /> Storage Location Bl� Et. Screen <br /> � 5. <br /> fy Slot size - ra ol- <br /> ` <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter pack type/size <br /> Mix Ratios Surge Block: - (y/ n) <br /> ipstallation Method Discussed vrith geologist: - (y/ n) <br /> Quantity Installed Type of rnetliod <br /> Ef i 29 29 <br />