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s <br /> C;1nC0NITOR`INb WELL INSTALLATIONRL;-r�F) <br /> Date: ! 'Z7� CONSTRUCTION <br /> Premise Address: 2-33 Cc) &Zcgr. _ Total Depth ZD !i <br /> Screen Length (from) ZZy (to) <br /> Well No.: Filter Pack (kom} (to) y <br /> •: Bentonite - {from) (to) Z <br /> Inspector: Grout (from) {to) O <br /> �//�� �/ b,3Jr• }` Drilling rig type In 00 <br /> Permit No. Auger O.D. I.D. I' <br /> Completion_ - Stove pipe/christie box .(circle one)" , <br /> Drilling Company: <br /> Driller. Y' / casing <br /> height <br /> Consultant €; <br /> Geologist <br /> l' COMPLETION CNRtSTY-BOX <br /> SPECIAL PERMIT INFO. ! Ground g tt <br /> Distance to sewer line groutMM,1 <br /> Domestic well on site - {y n - ;, Z, <br /> If yes, location and distance <br /> A <br /> SAMPLING A slotsad = , f <br /> G wcaon = 4 <br /> Holding Temperavavw Pack <br /> ture <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ _ ,• '. s } <br /> SPOILS :- <br /> Storage MethodP"" MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) 2iy �' <br /> Storage Location Casing type <br /> Blank 5 ft. Screen <br /> r <br /> Slot size O.W, �! ' <br /> GROUTING _ ,4 Bags cement <br /> �j Buckets bentonite <br /> Depth to water ^ Tt Bags sand/gravel f <br /> Mix Ratios d— Filter Pack type/size 3 <br /> Installation Metho , x = Surge Block: - (y/n] <br /> i. <br /> Quantity Installe_d - 3 " : , s. Discussed with geologist: - {y,/ n) � <br /> Type of method <br />