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MONPfORiNG WELL INSTALLATION REP-ore <br /> Date: �Z 6 9 CONSTRUCTION J <br /> Premise Address: 4*4 C" Total Depth <br /> Screen Length (from) r (to) 13, <br /> Well No.: F"V V l - - Filter Pack (from) r (to) 3.-._ <br /> Bentonite (from) t Z' (to) 17, <br /> Inspector: B� Grout (f om)�_�_(to) <br /> P Do �'2 Drilling rig type <br /> Permit No. G� Auger O.D. �� I.D. q-, z5 ' <br /> Completion -Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> �Ci � ' I casing <br /> Driller. l Y � :1eight <br /> Consultant��'� 1 <br /> Geologist CROL IASCJ l ��� D <br /> tsF_-Gq ION Cts VM_aOX <br /> C COMP=ICN <br /> CUOUSPECIAL PERMIT INFO. � <br /> 5 � <br /> grocR <br /> Distance to sewer line Cl�,as <br /> Domestic well on site - ( y/ n ) '[Alb630j <br /> If yes, location and distance - k. <br /> n, ��� �� • �- - <br /> ra,ue,Q 3 <br /> SAMPLING �`" r WOE <br /> ascan _ J <br /> Holding Temperature _ 7"Pacit <br /> Method .' <br /> Screening Method 1 OD <br /> Tracking Sheet - C y/ n ) � <br /> rL rL <br /> SPOILS <br /> Storage Method '' MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n <br /> Storage Location �Y S i Casing type \ <br /> Blank 2 green <br /> S�,yA� Slot size (V� <br /> GROUTING S� Bags cement <br /> I I„5 Buckets bentonite <br /> Depth to water �J Bags sand/grav <br /> Mix Ratios Filter Pack type/ e <br /> Installation Method Surge Block: <br /> Quantity Installed - Discussed •th eologis - / n) <br /> Type of method <br /> EH 29 <br /> cC <br /> Cor ll <br />