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Date: CONSTRUCTION <br />)NITORING WELL INSTALLATION REPC <br />Premise Address: <br />Inspector: <br />Permit No. 9/t6,Y <br />Drilling Company: tathit <br />Driller: <br />Consultant .4,,,124 likeiZe <br />Geologist <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site - y /CD <br />If yes, location and distance - <br />SAMPLING <br />Holding Temperature <br />Method .64-e ic9a-cit-A <br />Screening Method ,'?2 <br />Tracking Sheet - ( a) <br />ZIO/ tikdig 6—jrir <br />Well No.: <br />SPOILS <br />Storage Method <br />Contamination Noted - n) <br />Storage Location 7 C.hde <br />GROUTING <br />Depth to water <br />Mix Ratios <br />Installation Method /Cii-PiA-e 1/L44.- ./11-ip-411,0 <br />Quantity Installed <br />Slot size 0/0 <br />Bags cement <br />Buckets bentonite 2-p.tee. <br />Bags sand/gravel /3 <br />Filter Pack type/size <br />Surge Block:- n) <br />Discussed with geologist: - <br />Type of method <br />2-1 <br />Total Depth <br />Screen Length (from) <br />Filter Pack (from) <br />Bentonite (from) <br />Grout (from) <br />Drilling rig type <br />Auger 0.D. /2- <br />(to) (2,k6 <br />(to) • 5.3 <br />(to) 3 <br />(to) C <br />Completion. Stove pipe/christie box . (circle one) <br />7- height <br />casing <br />ABOVE-GRO(JND <br />COMPLETION <br />. ft. <br />slotted <br />Lec.jon <br />ar e. ft. <br />Blank •Z 3 ft. Screen /5 <br />MATERIALS/DEVELOPMENT <br />Casing type /91/e setciv <br />•