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jNITORING WELL INSTALLATION REPO,, <br /> ' Y <br /> Date: f�I 1 CONSTRUCTION <br /> 2� b M Otg'L w bsr p/XIZGcS(.) Total Depth <br /> Premise Address: Screen Length (from) <br /> Well No.: �"(o LCIS Jt Filter Pack (from) ' (to) !08 <br /> Bentonite (from)--42a—(to) <br /> Inspector, �J• �' � Grout (from) (0- (to) �- <br /> Drilling rig type 7 C At t� al —,. <br /> Permit No. Auger O.D. .2b I. �'2� <br /> . Completion - Stove pipe/ sue box circle one) <br /> Drilling Company: <br /> Driller: lug\ FMI <br /> Y casing <br /> 1 I it, <br /> height <br /> Consultant l i t a Pk l l�l- <br /> Qtw� c�(�sr1�t�1t <br /> Geologist L}1 ABOVE-GACUND <br /> COMPLETION CF6i M41OX <br /> COMPLETION <br />{ SPECIAL PERMIT INFO. ®Ground S'++ <br /> Distance to sewer line _ oraII <br /> Domestic well on site - W n) 1 'PW ft. <br /> If yes, location and distance - yry tL <br /> p•P _ Bunn t_�c_ _ :: <br /> V0. O <br /> _ YO. <br /> 4 '�^• G <br /> SAMPLING abtai i i <br /> Holding Temperature °L = Brava pack <br /> Method UiL t 1(c <br /> Screening Method <br /> Tracking Sheet - / n) d +; <br /> y <br /> tt. <br /> SPOILS <br /> Storage MethodVQleWF I S_ MAT ERIALS/DEVELOPMENT <br /> Contamination Noted - (y n <br /> Storage Location ob) S t,Tr Casing type 5t'A- Q t) 4 OV L <br /> Blank 1 trj ft Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios h _ Filter Pack type/size t utJt� �sf1 nl<_ <br /> Installation Method V1M`,',V r,LO Surge Block: - (®/ n ) <br /> Quantity Installed Discussed with geolo ist: - (V n ) <br /> Type of method ��±i/ YLgs�4'N <br /> EH 29 29;• <br /> MO- D15- 5 <br />