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M ,141TORING WELL INSTALLATION REPOnfi <br /> 9 c� �Z,V <br /> Date: ` �Z / 0, Z CONSTRUCTION <br /> Premise Address: ie�K 9 QJy Total Depth <br /> Screen Length (from) /l)OwQ <br /> Well No.: 7 Filter Pack (from) SU (to) t U <br /> Bentonite (from) 10 (to) g <br /> Inspector: _ Grout (from)— V- (to) <br /> �q1 p Drilling rig type 64 ^ti 7� <br /> Permit No. ��°/po Auger O.D. g I.D. <br /> Completion- Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: 3&5? * L casing <br /> , L height <br /> Consultant /f <br /> Geologist ABOVE-GROUND <br /> OX <br /> COAPLETION IS11 8ON <br /> C ON <br /> SPECIAL PERMIT INFO. Ground Surface <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - O ft. <br /> ft. - <br /> a <br /> m <br /> .. C <br /> SAMPLING monad <br /> �C <br /> aac or, <br /> Holding Temperaturegnvel Pack <br /> Method 'A <br /> Screening Method U\J^ <br /> Tracking Sheet -((y n) <br /> 5o tt. tt. <br /> SPOILS <br /> Storage Method OlL C LG.-'te-t MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) ;rI Sr 4o PVL <br /> Storage Location Ad Casing type <br /> Blank Screen —ft- <br /> Slot <br /> Slott ssize <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water z �40 Bags sand/gravel 1A 3 <br /> Mix Ratios -l6 *I Zo Filter Pack type/size 3 <br /> Installation Method Surge Block: - (y <br /> Quantity Installed Discussed with geologist: - (y O <br /> Type of method <br /> EH 29 29 <br />