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�NITORiNG WELL INSTALLATION REPO <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth �� N <br /> 1' ` ; '''� Screen Length (from) (to} <br /> Well No.: t Filter Pack (from) 'l (to)- <br /> Bentonite (from)S, (to) <br /> Inspector: . �5�i1,�B ��f°�:�E-. Grout (from) (to) <br /> Drilling rig qqe <br /> Permit No-21- Auger O.D. I.D. <br /> •� �,+ Completion - Stove pipe/christie box (circle one) <br /> Drilling Company- <br /> Driller: <br /> om anDriller: I�`-0eaaLng <br /> height <br /> Consultant& lb`s i <br /> Geologist -i.;=L'...k T <br /> I` /ABOVE-GRCIJND CiiMSTY-80X <br /> !? € COMPLETION COMPLETION <br /> ,I <br /> SPECIAL PERMIT INFO. . Ground Surface <br /> � r <br /> Distance to sewer line u... i 1i=.� grout <br /> Domestic well on site - (y/ nfL <br /> ) <br /> If yes, location and distance - <br /> JI <br /> SAMPLING <br /> cn <br /> Holding Tc erature <br /> Method �i; :. €. paac y <br /> Screening Method <br /> Tracking Sheet y n ) <br /> I: <br /> SPOILS <br /> ' l <br /> Storage Method �- Oi 'dI € MATERIALS/DEVELOPMENT ! <br /> p.: <br /> Contamination Noted y n) <br /> Storage Location_ - 545 edu�c ✓���� Casing type, /��/ <br /> Blank ft. Screen ft. <br /> ' Slot size .010 <br /> GRO[JTING - Bags cement <br /> Buckets bentonite <br /> Depth to water . Bags sand/gravel <br /> Mix Ratios i. -%`.;,j';f Filter Pack type/size 7i <br /> Installation Method "�I �'il f' Surge Block: - ( y n <br /> Quantity Installed 3:. �i:=,f�" 'l. Discussed with geopgist: - y�/ n) <br /> Type of method !�A / <br /> EH 29 29 <br />