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F I <br /> _. JNITORING WELL INSTALLATION REPOt,. <br /> Date: / �� Z , CONSTRUCTION <br /> Premise Address: Total Depth 3� _ <br /> //ta" v Screen Length (from)_ -(to) <br /> Well No.: Filter Pack (from) 3 (to) <br /> Of 0 Bentonite (from) (to) C� <br /> Inspector: Grout (from) -(to)�— <br /> �// Drilling rig type <br /> Permit No. 217"to Auger O.D. 77 I.D. <br /> Completion - Stove pipe/christie box circle one) <br /> Drilling Company: <br /> Driller: _ l 3 casing <br /> ,_height <br /> Consultant C'v' <br /> Geologist ����^" •_ <br /> ABOVE-GROUND Ct�A1STY-BOX <br /> COh9LETION COMPLETION <br /> SPECIAL PERMIT INFO. Cirnund Surface <br /> Distance to sewer line AIN X gra <br /> Domestic well on site - (y �d ft. <br /> If yes, location and distance - ft• <br /> m <br /> O <br /> C <br /> _ � O <br /> SAMPLING slotted <br /> aac�on <br /> Holding Temperature = R, V�Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) 2�� <br /> Storage Location Casing type <br /> Blank to ft. Screen /0' ft. <br /> Slot size o <br /> GROUTING Zergrcement Z$Z <br /> _ Buckets bentonite <br /> Death to water �•� Bags sand/gravel S <br /> Mix Ratios 744Z, Pit T4 11 ✓ Filter Pack type/size 2 ►Z <br /> Installation Meth d Cfity Surge Block: - (ygiost-_( <br /> Quantity Installed 0 -e" <// Discussed with gey n ) <br /> Type of method <br /> EH 29 29 <br /> io �? <br /> /o,,s, <br />