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PNITORING WELL INSTALLATION REr, <br /> Ne al u'kc <br /> �l �aa��sn �3$ <br /> Date:_ CONSTRUCTION '7 <br /> Premise Address:_ _1 a t D 'c Total Depth <br /> Screen Length (from) (to) <br /> Well No.: /, Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: r Grout (from) (to) <br /> (pDrilling rig type e <br /> Permit No. `-t 3 D � � Auger O.D. 145, <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: 69 <br /> Driller: " .k1.2'7 <br /> casing <br /> m height <br /> Consultant <br /> Geologist Cd 5 r "a n is <br /> 39.3 3 ABOVE-GROUNCOMPLETIOND cConP�oeiSPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> n. <br /> AINI <br /> I1S = <br /> SAMPLING <br /> .bid <br /> wc5on <br /> Holding Temperaturegravel <br /> Method o _ P <br /> ack <br /> Screening Method /XAa2 x _ <br /> Tracking Sheet - (y/ n ) �J <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) a/l p , <br /> Storage Location Casing type i V <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <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 />