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CNITORING WELL INSTALLATION REPOI <br /> Date: t l <br /> /���' CONSTRUCTION <br /> `7 <br /> Premise Address: 4t Total Depth <br /> Well No.: <br /> I )2 p Screen Length (from) /05 (to) 4'0 <br /> 1=�W f� Filter Pack (from) (f (to) <br /> Bentonite (from) 36 (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> f Completion -Stove pipe/cluistie box (circle one) <br /> Drilling C�omppaan3r <br /> Driller: Lir ✓` 5 ✓ SKr^ casing <br /> / r %I5 height <br /> Consultant & � � QQ 4w,.5t" 17MT <br /> yb , 11G� l6 F 105 <br /> Geologist Akud we . <br /> _ uABOVE-GROUND <br /> fro Push COMPLETION CHR*1Y-BOX <br /> SPECIAL PERMIT INFO. darn Ground Surtax <br /> Distance to sewer line grout <br /> Domestic well on site - (y n <br /> if yes, location and distance - ^ ft. <br /> _ <br /> T40 , <br /> SAMPLINGstarted <br /> otted <br /> soccn <br /> Holding Temperat� lgl UG <br /> Method ir( ID •'"a <br /> �gat <br /> 'vd�adc <br /> 46 0 T <br /> Screening Method y 5° <br /> Tracking Sheet n ) <br /> &5 '15 fin. 1 F _ 5 fL <br /> SPOILS n <br /> Storage Method d (r MATERIALS/DEVELOPMENT <br /> Contamination Noted -{yn/f �3�(G <br /> Storage Location n Q_Casing type r <br /> Blank 4 0 'ft. Screen .2ft. <br /> N, Slot size <br /> GROUTING .. Bags cement <br /> Buckets bentonite <br /> Depth to water 52 Bags sand/gravel <br /> Mix Ratios Filter Pack type/ ize <br /> installation Method a•V t4 , t L U Surge Block: - / ti-) <br /> Quantity Installed Discussed with geologist: .01;q) <br /> A <br /> (� Type of method 1550,E O/ <br /> EH 29 29 �Ab ,, q4l h VBG: <br /> j <br /> rN <br /> 1 <br />