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-w(ONITORING WELLINST <br /> �Tl <br /> REPORT <br /> Date: 3 �'S vOON <br /> Premise Address: Total Depth <br /> Screen Length (from) (to)�� <br /> Well No.: Filter Pack (from) —(to).�� <br /> Bentonite (from) (to)�..� <br /> Inspector.„� r+n Grout (from) (to) <br /> DrAling rig type <br /> Permit No. Auger O.D. LD. <br /> Completion-Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: cas inq <br /> f _ T <br /> height <br /> Consultant 7 �- T <br /> Geologist in�- T <br /> ABOVE-GROUND qHRIS 41OX <br /> OOMPLEMN OOMPI.E1 M <br /> SPECIAL PERMIT_iNRO Gro+rd Strfaas <br /> Distance to sewer line <br /> Domestic well on site - (y/n) � <br /> If yes, location and distance - <br /> [t. <br /> SAMPLING <br /> "Cdcn <br /> Holding TerqpeFature <br /> Method f `r <br /> Screening Method <br /> Tracking Sheet / n) -_ <br /> Storage Method 1`�4. �T�-f ?SD EVELo <br /> Contamination Noted - (�-n} <br /> Storage Location `ii��'--�t CC Casing type <br /> Blank fL Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> �` Buckets bentonite <br /> Depth to water 3.7 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 <br />