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'i <br /> CNITORING WELL INSTALLATION REP -, . f <br /> t ! <br /> I Date: d '�� ' CONISTRUCTION. <br /> it ,I <br /> Premise Address: `(01 Mcsnl Totall�DepthlI <br /> Screen Length (from) ' (to) �2 <br /> Well No.: Filter,Pack (from) (to) M <br /> Bentonite I (from) (to) /7 <br /> Inspector. � � Grout (from) 17 __(to) -�- <br /> Drilling rig type„ <br /> Permit No. �l Augei O.D. <br /> Completion p Stove pi a/christie-bo circle one) <br /> Drilling Company: <br /> Driller: L�n�'S � � " casing <br /> Tilheight . <br /> Consultant a;-Ut.0 6ys-ps.:! t �` <br /> Geologist &At.-,P t M7E ii <br /> ASOVE-GRCUNO CHRM-BOX <br /> COMPLEMN C�.IPLETION <br /> SPECIAL PERMIT INFO. II G= d Sutaca <br /> i� <br /> Distance to sewer Iine <br /> �rcut <br /> Domestic well on site - / n) <br /> If yes, location and tance - <br /> jl �I• r _ <br /> SAMPLING ,i: at orod — C <br /> sacicn � 1 <br /> Holding Temperature i3 Pa <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n } A, <br /> a <br /> SPOILS <br /> Storage Method IJ 4*lqcf;�' )q,* &rZC eoJun.u�b MATERIM&pEVELOPMENT <br /> Contamination Noted - n) —.9—yOpv^ <br /> Storage Location.. haI 51 _.. Casing type;i <br /> 4" 40 ' k.- <br /> Blank ZZ ft. Screen ft. <br /> Slot size i d 10115b - <br /> GROUTING LL Bags cement Lu�+J <br /> Buckets beritonite �2 � <br /> s <br /> Depth to water Bags isand/gravel <br /> Mix Ratios _ FiIter;Pack type/size a !tel <br /> Installation Method j1ajZtb - Surge Black: - / n ) <br /> Quantity InstaIled Discussed ;th geologist: - (y <br /> Type"o ethod �Y <br /> EH 29 29 <br /> r <br /> cc II <br /> _, w <br />