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`.JNITORING WELL INSTALLATION REPOil.,,+ <br /> Pe-4 I r4 4f <br /> CONSTRUCI70N <br /> Premise Address:_ 2 9 �,4o,,a J Q. <br /> Total Depth_ S <br /> Well No.: L W . )D z Screen Length (from) '!' <br /> Filter Pack (fr <br /> i <br /> Bentonte Mom) <br /> t , <br /> Inspector. 1'j�,, � �w (to) 33 <br /> �l1 Grout (from) 3 3, (to) z <br /> Q s 2 Drilling rig type 13R - 8 I <br /> Permit No. <br /> 9 Auger O.D. A-i I.D. /. 2. <br /> Drilling Company: <br /> Completion - Stove pipe/ tstie b (circle one) - <br /> $ V►� ..�r, <br /> � �rd1 -J'if S-f'a33'-fa <br /> o s 4 <r9 ra VO4 I-9t e,,• <br /> Driller: cram k re Z casing <br /> Ass',Sf-Q s % 'L>4v d &414d V#n F'140-do he; <br /> Consultant 6,e o <br /> Geologist 06& 412 a LC 1 e -- <br /> ABOVE-GROUND <br /> COM?LEfION COMPLETICN <br /> SPECIAL PERMIT INFO. 11 Ground Su lace <br /> Distance to sewer line �6 L SD A grout <br /> Domestic well on site - (y - ft. <br /> If yes, location and distance - • , S ft. <br /> C�A 4-o I 0 <br /> SAMPLING — n rYt <br /> ¢ <br /> 156MA SiJJl��c1!x„45'— 33 •loro.i .r = <br /> �dV.i 33'-17' soricn <br /> Holding Temperature OSI A �., S <br /> _ <br /> t o , 9aY9t Fack <br /> Method SS 1 is "S 7 —' <br /> Screenin,y Method — <br /> Tracking Sheet - (y/ n A 3 7 . —' <br /> SPOILS <br /> Storage Method s' V l MATERIAM/DEVELOPMENT <br /> Contamination Noted - n) -' // <br /> Storage Location 07'1 S,7�G Casing type o2-!hr cSGt2i X14 a <br /> Blank SF ft. Screen z R• <br /> Slot size ` AL 0 <br /> GROUTING Bags cement 1.2 <br /> 3/9 t—Buckets bentonite .55* JoA44S <br /> Depth to water cl/rm Bags sand/gravel -� <br /> Mix Ratios )� 9SI-IJP X� Filter Pack type/size ' 3 <br /> Installation Method P/!"-f Surge Block: - ( y/9) <br /> Quantity Installed &.ej.-Z Discussed with geologist: - / n) <br /> ./pZ Type of method — <br /> EH 29 29 <br />