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WITORING WELL INSTALLATION REPO! <br /> Date- ' - r I� CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: W Filter Pack (from) S (to) 4� <br /> Bentonite (from)4 —(co) U 1 ' <br /> Inspector. Grout (from) (to) <br /> Drilling rig type (n s ( �� ee n <br /> Permit No. Auger O.D. I.D <br /> ( ��__ ` Completion - Stove pip ritstie bop (circle one) <br /> Drilling Company: �"I3C2��A n r <br /> Driller. casing <br /> height <br /> Consultant_ LAIA&a <br /> Geologist a-fl �o% !' _ <br /> ABOVE•GACUND CHMSfY-a0X <br /> 00NFL7CN COWN-EnCN <br /> SPECIAL PERMIT INFO.Sufac+ +��� <br /> great <br /> Distance to sewer line <br /> Domestic well on site - (yn 4( It. <br /> If yes, location and distant s (t. <br /> = o <br /> = c <br /> — a <br /> SAMPLING >slorod <br /> taC:Cn —_ <br /> Holding Temperature = yraval Fast <br /> Method a L� C >: _ <br /> Screening Method A� r. <br /> Tracking Sheet - ( y/ n ) is _ . <br /> fL <br /> 1�4�Y�.y"yL <br /> SPOILS ! 1 _ <br /> Storage Method S A ` IAI� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n L <br /> Storage Location Casing type <br /> Blank _fL Screen <br /> Slot size 0 ( <br /> GROUTING Bags cement ! <br /> Buckets bentonite <br /> Ss � <br /> Depth to water <br /> Ba sand/ vel " <br /> Mix Ratios Filter Pack type/size Ann j, _ a I2- <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed D Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />