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(�NTTORING WELL INSTALLATION REPO,.; <br /> t <br /> Date: V I CONSTRUCTION <br /> Premise Address--455Total Depth <br /> Well No.: Screen Length (from)_ �a _(to)_ <br /> Filter Pack (from)_ _ 30 (to)-_ 4— <br /> n/� Bentonite (from) 4-- (to) ?, <br /> Inspector: I " ! Grout (from) -(to) <br /> Drilling rig type 1Z1& t!5 9zn— _ <br /> Permit No. Auger O.D. t <br /> Completion - Stove pipe/ uistie box ircle one) <br /> Drilling Company: I <br /> I <br /> Driller: C <br /> �� <br /> Consultant heightr <br /> Geologist <br /> ABOVE-GRCUND CFAWY-SOX <br /> CONFPL.I TCN CCMPLEnON <br /> SPECIAL PERMIT INFO. ground Swiact <br /> Distance to sewer line -D ofcut <br /> Domestic well on site - (y/ n 2 <br /> If yes, location and distance - <br /> 9n - <br /> • <br /> SAMPLING - Q <br /> 1 sac�cn <br /> ��. <br /> Holding Temperature - ;,�: <br /> ack <br /> Method 4 l <br /> Screening Method — <br /> Tracking Sheet - (y/ n ) .4 <br /> ft. IFtt- <br /> 6y <br /> SPOILS - <br /> -TD 29•$ <br /> Storage Method G. MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n) �j� Q <br /> Storage Location Casing type 1 ` t V <br /> Blank ft. Screen <br /> Slot size a7�o <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel 1 L (SU r t-f <br /> Mix Ratios Filter Pack type/ 'ze <br /> 49t 25=- <br /> Installation Method ' Surge Block: : y <br /> Quantity Installed Discussed wit o St. - (y/ } <br /> - Type of method <br /> EH 29 29 J` �X- �t/� <br /> rq ae&*� <br />