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24 NITORING WELL INS TALlknI ON REPORT <br /> N - <br /> Dare : CONSTRUCTION <br /> Premise Address : � 1nD �o N Total Depth <br /> / Screen Length (from) D (to) GS <br /> Well No . : Va) �?11Filter Pack (from) 0 (ro) lYr# <br /> Bentonite (from) / T (to) 12 <br /> Inspector: JAe Grout (from) / 2. (to) O <br /> q 7 Drilling rig type CA�E 750 <br /> Permit No. / Z ' � y f3 Auger O .D. ig '/z. ID. 3j P <br /> / Completion • Stove pipe/chrisde box (circle one) <br /> Drilling Company: 9 <br /> casing <br /> Driller. l <br /> he ; <br /> n rr7l <br /> Consultant <br /> A <br /> Geologist ABOVE-GACUND ISTY-aC <br /> COWLEi ICN C^ � iICN <br /> Grvund .StLrfwt <br /> SPECIAL PERMIT INFO . <br /> /Y+ grout <br /> Distance to sewer line_ Y+ � z <br /> Domestic well on site - ( y / n ) ft. <br /> If yes , location and distance - r 5 ft — tt <br /> 3 <br /> o <br /> dotted <br /> c IPrraiG ax-.'On <br /> Holding Temperature /✓D ww o — �" `I <br /> Method <br /> Screening Method / 7J <br /> Tracking Sheet - n ) �d <br /> tt. tt. <br /> SPOILS Q iz�q 3S ' <br /> Storage Method ONr rMAi RIALS/DEVELOPMENT <br /> Contamination Noted - y n ) l 0 <br /> Storage Location (Th ai. a Casing type 7 Y <br /> Blank /.5 fr. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonire <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size < <br /> Installation Method Surge Block: -c( yam) /✓ <br /> Quantity Installed Discussed-cvith- geologis . tv n ) <br /> No'tA: <br /> «V Ctl�,o ✓11 o T d4 <br /> VW ! /� ee aec �r vrY to � �' 7� <br />