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4 <br /> MONFTORINGWELL INSTALLATION REPORT <br /> CONSTRUGT30N <br /> Date: Gs J <br /> Total Depth (to) <br /> Premise Address: Screen Length (from) <br /> :Filter.Pacl`� (from) (CO) <br /> well No.: !t Bentonite (from) (to) <br /> : Grout (from) (t°) <br /> Inspector. Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: <br /> cas:rsg <br /> Driller: he��ht <br /> _ Iv .y <br /> Consultant <br /> Geologist A.o�-E-GRCUND <br /> CompLEMN <br /> Cx'.x:r�S�zfx� <br /> SPECIAL pERMiT INFO, Grout <br /> Distance to.sewer lineft. <br /> Domestic well on site = { y <br /> If yes, location and distance • <br /> �hr O <br /> ' O <br /> i <br /> SAWLING iQCSCn 'f �� <br /> Holding Temperature <br /> Method -' <br /> Screening Method : <br /> Tracking Sheet - (Y/ n) <br /> SP_ LS <br /> MATERIALS (IPMENT <br /> Storage Method <br /> Contamination Noted- (y/ n) Casing type i <br /> Storage Location Black fru Screen <br /> r � <br /> Slot size <br /> Bags cement b <br /> GR___L•NG Buckets bentonite <br /> �l' ' SZ37 Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mist Ratios Surge Block: - (Y <br /> pstalladon Me od Discussed vrith geologist: - (y/ n) <br /> i Quantity Installed Type of Mctliod <br /> EH 29 29- <br /> a <br />