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UNITORING WELL INSTALLATION REPO <br /> Date: �� l� R CONSTRUCTION <br /> Premise Address: Total Depth <br /> I '. ` �� " Screen Length (from) (05 (to) 40 <br /> Well No.: Nl W Filter Pack (from)&(to) 5T <br /> Bentonite (from) (to) 3 L <br /> Inspector. �f.Uf'a'd Grout (from)- (to) a <br /> n 2 2 Drilling rig type CM <br /> Permit No. Auger O.D. S" I.D. <br /> Completion - Stove pipe/ (circle one) <br /> Drilling Company: SC,S <br /> Driller. IuLI b'!i4 casing <br /> Theight <br /> Consultant (0T L <br /> Geologist <br /> RoU �Aouvi <br /> ABOVE-GROUND CHRZ*TY-30X <br /> COMPLEWN COMPLETION <br /> SPECIAL PERMIT INFO. Ground Satan <br /> Distance to sewer line PIZQfO� <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - tL <br /> a tt. <br /> in ALM13 <br /> _ <br /> t. <br /> ow 4 <br /> SAMPLING Wi�rn abred <br /> soc9on <br /> Holding Temperature <br /> Method Q'10-Q 62 <br /> Screening Method PID = i <br /> Tracking Sheet • (y/ n ) ` __ I <br /> Nage: ('�✓t k,AMlvtCt��6✓I y�d�l tL = to rJ n <br /> SPOILS - (00 - odor t soil �c dorelia) <br /> Storage Method �VOY"-S 1, MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n ) 2n AUG <br /> Storage Location SAJP Casing type <br /> 1-10t,dmo- �{ Blank <br /> &4e, 40 ft. Screen 5 2ft• <br /> .� � Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite I '/Z <br /> Depth to water JS Bags sand/gravel_ too Ito <br /> Mix Ratios 5 1jQA4Y Filter Pack type/size *t <br /> Installation Methodv�� Surge Block: - ( y/(it <br /> Quantity Installed o Discussed with geologist: • (0/ n) <br /> Type of method <br /> EH 29 29 <br />