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%,,AONITORING WELL INSXpU.VReN REP. <br /> Date: Z �t7— CONSTRUCTION <br /> Premise Address; soo (, F-m Total Depth <br /> Screen Length (from) (to) <br /> Well No.:_AU'Lu1j , SUS ("�� Pt-Z, Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No.5f--6 �17� Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> 7height: <br /> Consultant' <br /> Geologist + <br /> ABOVE-GRCUND <br /> cOWLET40N CHR S 43OX <br /> SPECIAL PERMIT INFO. Ground Suriaca <br /> Distance to sewer line grout <br /> Domestic well un site - ( y/ n ) T Ito <br /> If yes, location and distance - ft. <br /> ft. <br /> SAMPLI/Tempature <br /> Holding <br /> MethodScreeniTrackiny/ n ) <br /> tt. <br /> SPOILS <br /> Storage Method MATERIALS EVEI.OPMENT <br /> Contamination oted - ) i, r.+ n <br /> Storage Locati '- Casing type oZ� `llk> <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios n Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Instal leDiscussed with geologist: ( y/ n } <br /> Type of method_____ ^ <br /> EH 29 29 <br />