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�. ONITORING WELL INSTALLATION REPO, <br /> Date:tom/ �2,7—A l/ CONSTRUCTION <br /> Premise AddresglD LU � N,4 Total Depth <br /> p �y, S een Length (fr ) (to) <br /> Well No.: / l7 `� - �' ��j1 ee Pack (fro (to) <br /> � � Q Bentonite (from) (to) <br /> Inspector: !V Grout (from) (to) <br /> Drilling rig type <br /> Permit No Sp—*062-wq Auger O.D. %I.D. <br /> / n Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: �,.fia,<, �i..i. � <br /> Driller: --TT-- casing <br /> height <br /> Consultant_ T <br /> T <br /> Geologist —_.—_. �gpvE GR D <br /> COWLETIO Cl MPLE'-8OX <br /> COMPI.EiION <br /> SPECIAL PERMIT INFO. nd S �_ <br /> Distance to sewer line <br /> (�" grout <br /> Domestic well on site - ( y n ) ft. <br /> If yes, location and distance - tt. <br /> ft. <br /> a <br /> _ m <br /> _ e <br /> m <br /> SAMPLING clotted <br /> p tacdan <br /> Holding Teplpejture = gavel pads <br /> Method <br /> Screening Method = <br /> Tracking Sheet - y n ) _ <br /> SPOILS <br /> Storage Method AJA MATERIALS EVELOPMENT <br /> Contamination Noted - (y/9) <br /> Storage Location A2 4A Casing type <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 L..ru� Filter Pack type/size <br /> Installation Method' Surge Block: - ( y/ ) <br /> Quantity Installed Discussed with geolo 'st: - y/ n ) <br /> Type of method <br /> EH 29 29 <br />