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iytONITOAING WELL INSTALLATION RE�`�i - <br /> cr c -f6 <br /> OT -Eo,. s �z <br /> Date: /,l / 2; CONSTRUCTION <br /> Premise Address — �- ICt C h0L Total Depth_ <br /> „ Z./25 <br /> �` l J�� Screen Length (from) (to) <br />! Well No.: l Filter Pack (from) (to) <br /> W D L1 Bentonite (from) (to) <br /> Inspector. Grout (Isom) (to) <br /> Drilling rig type -, <br /> Permit No. Auger O.D. I.D. <br /> Completion -Stove pipe/ciZristie box (circle one) <br /> Drilling Company r V ! h.� S! TSD <br /> I I �o � <br /> Driller:_ b CU ('Z asing <br /> FM <br /> Consultant 7 <br /> Geologist 1 <br /> f.�L-"TfQN N3cx) <br /> ,. <br /> CaW EMN <br /> SPECIAL PERMIT INFO. SUfsc. <br /> Distance to sewer line �j ` <br /> Domestic well on site - ( y/ QY! <br /> If yes, location and distance <br /> f Y• _ � <br /> (05 P 01 VIA i4 <br /> y- Y <br /> SAMPLING �� I slotted � — <br /> y <br /> Holding Temperature 11 <br /> Method <br /> r �• <br /> Screening Method v.y - n1 <br /> Tracking Sheet -,( y/ a ) ��s i•�a <br /> SPOILS /� <br /> Storage Method_ �/ U MATERIALS E`JELOP?VIENT <br /> Contamination Noted - (y/ n.) <br /> Storage Location Casing type <br /> Blank fr- Screen fL . <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water '�� 5 Bags sand/gravel <br /> Mix Ratios o n;v­2 5 tt,4,i7v Filter Pack type/size <br /> Installation Methodr .i/N Iyi Surge Block: - (ya <br /> Quantity Installed v Discussed with ge Z" t: -0 n} I <br /> 1 r. Type of method <br /> EH ,9 29 1 <br /> 5b� Wes �+ . . <br /> ko �r s �s, -�' `z2 °ars °Pry <br /> • 1l,, A *tV <br /> c� �� D 0. , /10` -��0ziS fl11LV S la`�o Q -M" r_r�tf s : <br />