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'% .JNITORING WELL INSTALLATION REPG.-/ <br /> Date: d 11YI13 CONSTRUCTION <br /> Premise Address: I -ZO07 ��' am Total Depth <br /> r Screen Length (from) (to) <br /> Well No.- Y J 1& C 1'2 C="-3 Filter Pack (from) (to)� <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to)�_,,,, <br /> Drilling rig type <br /> Permit No.—93 � Auger O.D. I-D. <br /> Drilling Company: <br /> S Completion - Stove pipe/cltrlstie box (circle one) <br /> casing <br /> Driller: lam—�Um1n height <br /> Consultant �d�t —Rw <br /> Geologist r ! ACV U <br /> ABOVE-GRCUND CF Rtm-BOX <br /> CC MPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground S dace — <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - tt. <br /> ft. <br /> A P <br /> �t M <br /> SAMPLING iiot'.o.l c <br /> Holding Temperature / � � _ �Vol PaCK <br /> Method X11�" i •� �1 � <br /> Screening Method : -== <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method �l C MATERIALS EVEI.OPMENT <br /> Contamination NotedO( <br /> Storage Location �t _ Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water /V`� Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> /' / Type of method <br /> EH 29 29 U G� <br />