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NITORJNG WELL INSTALLATION RE* <br /> Date: ID�?'�I CONSTRUCTION <br /> Premise Address: b �Y`�' 54-, 5iPvrK&1 Total Depth 2q <br /> Screen Length (from) (to) It <br /> Well No.: Filter Pack (from) Zq (to) 11 <br /> r z Bentonite (from) l 7 ' (to) <br /> Inspector: Galfft� 60A-tAd . Grout (from) r C (to) 1 <br /> Q o alb 3 Drilling rig type Rk jEI <br /> Permit No. S �" Auger O.D. 17t I.D. 14•LS'� <br /> Completion - ove pipe cluistie box (circle one) <br /> Drilling Company: Vjowkjp(A <br /> Driller: n S casing <br /> height: <br /> Consultant L K S <br /> Get <br /> aZst- CCh�LEC1OND Ct�A1S1`(80X <br /> COMPLEEMCN <br /> SPECIAL PERMJT INFO. Ground SLrfa" <br /> Distance to sever line Cfovt <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ff. <br /> t a It, <br /> Z <br /> SAMPLING <br /> ,. <br /> t•acticn —_ <br /> Holding Temperature W* C <br /> Method <br /> Screening Method r> <br /> Tracking Sheet - ( y/ n ) <br /> 21, <br /> fto <br /> SPOILS <br /> Storage Method 5� VVI MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location 6ri5� Casing type 6th q0 WC <br /> Blank W y 3+ yA&X ft. Screen ID ft. <br /> Slot size .62- +fthe) <br /> GROUTING Bags cement Steed a H11b e^. rte, w/ ?_0OW6013 <br /> Buckets bentonite <br /> Depth to water 1���1 _ Bags sand/gravel 7 S SOIb, 6--l" <br /> Mix Ratios _ Filter Pack type/size 3 <br /> Installation MethodSurge Block: - ( y/Q) <br /> Quantity Installed_ Discussed with geologist: - (C/ n ) <br /> Type of method <br /> EH 29 29 <br />