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j <br />It <br />Date: 4 <br />Premise Ad ess { -7 W �/ <br />,6 Well No.: <br />ii <br />Inspector: <br />Permit No. 0 �v l�/i� F <br />ii <br />Drilling Company: <br />s <br />Driller: <br />Consultant G <br />Geologist c� <br />'I <br />IN <br />SPECIAL PERMIT INFO.�w <br />Distance to sewer line > <br />Domestic well on site - ( y' <br />If yes, location and distance - <br />1 Y <br />SAMPLING 4 r <br />' Holding Temperature <br />-C 1 <br />Method_ ± r <br />Screening Method <br />Tracking Sheet+. n ) <br />SPOILS <br />i,. <br />Storage Method <br />Contamination!:Noted <br />Storage Location ,k <br />TI <br />. ;I <br />GROUNG - <br />Depth to water = 3 <br />Mix Ratios R 0 <br />Ntt�ITORING :WELL INSTALLATION REPOrL <br />l <br />3�a 33 <br />is kt <br />A MATERIALS/DEVE <br />ip Z'S Casing type <br />Blank <br />Surge <br />Discussed with geo <br />Type of method <br />fr <br />CONSTRUCTION <br />Total Depth <br />If om) (to) 3 <br />Grout (fr°m <br />Drilling rig type <br />) (to) � <br />M <br />Auger O.D.�� $ I.D. <br />Completion -Stove pipe/chri <br />Screen Length (from) (to) <br />Filter Pack {from) i2-f-5(to) <br />Bentonite ( <br />stie box (circle one) <br />casing <br />he! gitt <br />�►SOVE-GfiOl1ND <br />COMRLEf 10N <br />C�noc�t�d <br />St�rtaas <br />. - r <br />slatted <br />fs <br />— <br />aac�on <br />=_ <br />G-IRtSTY-80X <br />COMPLF�EON <br />grout T L <br />3 <br />�,rayst pack <br />T <br />LOPMEIVT r� - <br />,t� v <br />. S •. ft. ,, Screen ! 5 ft. <br />Slot size <br />Bags cement <br />� Bucicets`bentonite-�• <br />�. •-•• • - `Z �+-�`- <br />Bags sand/gravel <br />�y Filter Pack type/si <br />Installation Method �� <br />eBlock:'- n ) <br />Quantity Installed I T� 10 's y n <br />s <br />EH 29 29 <br />