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is <br /> M ITORING WELi:._IN!1 TaIATION REPOnf <br /> 4�"Z Z CONSTRUCTION <br /> Date: „ <br /> ,Q y p� Q /�,•, I r ' <br /> Premise Address: Total Depth 4(ffo-mi) <br /> Screen Length 8.S (to) <br /> /A Filter Pack (from)' ��5 (to) /P' f <br /> Well No.: Bentonite (from) (ta) <br /> Inspector: Grout (from) (�� <br /> Drilling rig type- <br /> Auger O.D. LD. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: , . <br /> f= { casing-' 1JP <br /> \ <br /> Driller'_ height <br /> Consultant. ��� _ -.. . • aa' -' y _ . <br /> Geologist !a `a ABOVE-GROUND CwtSTY-BOX <br /> COMPLETION comnEnw <br /> : Ground Sur•hce <br /> SPECIAL PERMIT INFO.-' $ H <br /> Distance to sewer line \' / . <br /> Domestic well on site - (y <br /> If yes, location and distance v, ; <br /> 4 <br /> 4 1 tic iad c <br /> SAMPLING f Icany <br /> } <br /> Pack <br /> Holding Temperature <br /> Method <br /> Screening Method 4 N- Y r <br /> Tracking Sheet - (y/ n <br /> SPOILS ;,4 <br /> EVELOPMENT <br /> Storage Method nLG <br /> Contamination Noted - (y !. ''` <br /> Sy0 r Q✓/� " Casing type <br /> Storage Location_ Blank I$•5 4 , + ft. L Screen <br /> Slot size <br /> .� .. <br /> GROUTING 4� , � ! Bags cement .. <br /> Buckets bentonite <br /> Depth to water 1 x 1 Bags sand/gravel <br /> "� Filter Pack type/size <br /> Mix Ratios r 1 ''r-, '` Surge Block: - ('y/ n'.) <br /> Installation Method x Discussed with geologist: - (y/ n} <br /> Quantity Installed Type of method <br /> EH 29 29 _ <br /> • .: .. -- a f. O <br /> i� <br />