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-JNITORING WELL INSTALLATION REPOk . <br /> M <br /> Date : lm l $ CONSTRUCTION <br /> Premise Address : I . G( � l✓ ( b>D r�✓� Ll S d-�c Total DepthSO <br /> _ <br /> �5 Screen Length (from) w6o (to) air' <br /> Well No. : LA) _ K �' C� Filter Pack (from) (to) _ <br /> Inspector: r�Ml' \ Bentonite (from) - (to) l l <br /> Grout (from) }L (to)�C <br /> t4" Drilling rig type,__.0 W r,4a S <br /> (P <br /> Permit No, elf[�i a � 0 Auger O.D. V I .D. <br /> AM 1 L Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: ?Gh. Goin <br /> Driller:_ a66 , �t� [� <br /> � ✓� casing <br /> height <br /> Consultant ��.V�. p <br /> Geologist LckS V P /y •_ <br /> ABOVE-GROUND <br /> COMPLETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO, Ground Suriacs <br /> Distance to sewer 1 ' a proof <br /> Domestic well on ite - ( y ) <br /> If yes, location d dist e - ft• <br /> -1 S ft <br /> SAMPLING ft. <br /> SAMPLING <br /> �btted _ B <br /> sacian <br /> Holding Temperature P <br /> ack <br /> Method <br /> Screening Method Cp = <br /> Tracking Sheet - ( y 1 h <br /> $J , <br /> ft. LIE ft. <br /> SPOILS <br /> Storage Method 5-%5 95slAo^ L7j � MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type 40 RL4k IPU (� <br /> T <br /> Blank "r5 ` fr. Screen Aft. <br /> Slot size <br /> GROUTING Bags cement l <br /> Buckets bentonite l <br /> Depth to water L� - 1, Bags sand/gravelS <br /> Mix Ratios at to 0\� 400> Filter Pack type/size Z t2 <br /> Installation Methodw+• Il Surge Block: - ryy n ) <br /> Quantity Installed v Discussed with eologist - n ) <br /> lbw ix*i i Sh Type of method <br /> EH 29 29 '� 4c, XIC yp <br />