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°.._.1NITORING WELT.INSTAUATION REPOI� 1 <br /> DateCONSTRUCTION <br /> Premise Address: �� Total Depth ¢ a� <br /> Screen Length (from) P§ (to)�,,� <br /> Well No.: W b Filter Pack (from) (o4L.5 (to) 4� <br /> Bentonite {from) 414P (to) 41�' _ <br /> Inspector: Grout (from) to <br /> Drilling rig type i <br /> Permit No. 34.01 Auger O.D. I.D. >{:7.6 <br /> Completion - Stove pipe/christie box. (circle one) <br /> Drilling Company: <br /> Driller: cao f ng <br /> height <br /> Consultant <br /> Geologist G t ezn- '" <br /> / COQ -GFIOUND CSW M-BOX <br /> GOMPLETCN cOMPt noN <br /> SPECIAL PERMIT INFO. aroundSufact <br /> grout <br /> Distance to sewer <br /> Domestic well on site - {y/ n ) ft. <br /> If yes, location and distance - tt- <br /> SAMPLING dotia.l Y: <br /> Holding Temperature _4'� soden <br /> _ gnVo paw <br /> MethodXj <br /> +r' <br /> -� <br /> Screening Methodr� <br /> Tracking Sheet - (y/ n <br /> a....w.w.ir <br /> SPOILS ! <br /> Storage Method dN ALL- _ MATERIAIS/DEVE_LOPMENT <br /> Contamination Noted - Ul n ) gbApP% a J1 ' <br /> Storage Location Casing type <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water ' Bags sand/gravel <br /> Mix Ratios 3a Filter Pack type/size <br /> Installation Method Surge Block: - (43/ n ) <br /> Quantity Installed Discussed with geologist: - 0/ n} <br /> Type of method <br /> EH 29 29 <br />