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1 <br /> J47 <br /> "--'g0NIT0RING:WELL INSTALLATION REPO - <br /> ,H � vay�t pr�6a5 i <br /> Date: -31 y G '��� �� CONSTRUCTION <br /> Premise Address: Total Depth �^ <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: /j/G /7/ Grout (from) (to) <br /> Drilling rig type <br /> Permit No. �' s:z�`2 9 SZy36 Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant ,* 7q�C <br /> 7: <br /> Geologist <br /> ABOVE-GROUND MISTY-BOX <br /> COMPLE ZN COMPLETION <br /> SPECIAL PERMIT INFO. '0* �� <br /> Wil grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - © ah �,w ft. <br /> ft. <br /> v-, _ C <br /> SAMPLING , slotted — <br /> mon _ <br /> Holding Temperature ° �` s� gravel p�ic <br /> Method <br /> Screening Method = <br /> Tracking Sheet - (y/ n) — <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location, Casing type <br /> Blank ft. Screen ft. <br /> slot size <br /> GROUTING CAA kCV4:Te j//U2/�7 ��1�A4w�� k,ees Bags cement <br /> gnwf<v fv -lot:; e,—IJ Buckets bentonite <br /> Depth to water ✓I`'l'�>`sy�ase wlin Bags sand/gravel <br /> Mix Ratios Feu-v) aheO- Filter Pack type/size <br /> Installation Method b �` Sorge Block: - (y/ n ) <br /> Quantity Installed G� Discussed with keologist: -.( y/ n ) <br /> Type of method <br /> EH 29 29 <br />