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`%,,,JNITORING WELL INSTALLATION REPO,,.,' <br /> Date: j O F7 3 CONSTRUCTION <br /> Premise Address: �31 /V.• �� � /1 Total Depth <br /> Screen Length (from) (to) <br /> Well No.:_ �1 Sfj ��� Filter Pack (from) (to) <br /> C Bentonite (from) (to) <br /> Inspector. J/ �I ,6 c�S� � Grout (from) 3s— (to) Q/ <br /> Drilling rig type <br /> Permit No. 9 3✓6207 2_ Auger O.D. P11 I.D. <br /> vw\ Completion - Stove pipe/chrisde box (circle one) <br /> Drilling Company:-„� aP _ _- <br /> Driller: casing <br /> Wff,� <br /> T height <br /> Consultant l l�� 7 �l L - ___ <br /> Geologist fir/lZLa= '64—40"/- <br /> ABOVS-GROUND CHAJM43OX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Swfac# <br /> Distance to sewer line Ll� grout <br /> Domestic well on site - (y/ n) �`ft. <br /> If yes, location and distance - M <br /> /14 fi34 R. <br /> SAMPLING <br /> u�o aocycn <br /> Holding Temperature " <br /> Method �� = 9M Pack <br /> Screening Method —_ <br /> Tracking Sheet - (y/ n ) _— <br /> ft. ft. <br /> SPOILS <br /> Storage Method SS `C J MATERIALS/DEVELOPMENT <br /> Contamination Noted -G n�)f <br /> Storage Location X13,7 Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 J <br /> LQ0�1 4"' J�f�� Q1/ <br />