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CNITORING WELL.INSTALLATION REPO�A <br /> I ifi <br /> Date: CONSTRUCTION <br /> �4 � / <br /> Premise Address: a a Total Depth <br /> Screen Length (from) C7D' (to) <br /> Well No,: /WW Filter Pack',' (from) ?d (to) _ <br /> Cga/ <br /> Bentonite ,; (from) (to) 6Inspector. _ : Grout {from)_ j�,,, {to) <br /> Drilling rig!type <br /> Permit No. Auger O.D.I I.D. �'75`` <br /> Completionr- Stove pipe/clu-istie box (circle one) <br /> ' Drilling Company:, <br /> k Driller: "e411casing <br /> �..^, 1k he;ght <br /> Consultant r <br /> Geologist : <br /> ABOVE-GROUND CHRM43OX ' <br /> cOtivLrnbN <br /> SPECIAL PERMIT INFO. i� Ground 5 COMPLETION <br /> Distance to sewer line '+ N grout <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - tL <br /> �` " Vic• �' � , <br /> SAMPLING — o <br /> aodcn x• <br /> i <br /> Holding Temperaturepack <br /> j� N <br /> Method <br /> Screening Method # ,W <br /> Tracking Sheet (y/ n ) <br /> SPOILS <br /> Storage Method C <br /> MATERIALS/DEVELOPMENT <br /> Contamination Noted <br /> 'Ir Stara e Location p �j O <br /> g Casing type-iM / y�� t..2 <br /> Blank Xo':.-r ft. Screen 2-o' ft. <br /> Slot size <br /> GROUTING _ Bags cement <br /> l Buckets bentonite <br /> Depth to water f� Bags sand/ 6vei <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 /> r <br /> �r• ii <br />