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41 <br /> JNITORING WELI.INSTALLATION REPO.,, <br /> Date: . , 2 L CONSTRUCTION <br /> Premise Address_: - )f t-�S„L_- t IAV Total Depth <br /> Screen Length (from) {to} Via. <br /> Well No.: ,,, (.N - Filter Pack (from) 632- (to) a <br /> Bentonite (from) (�Clc7 (to) <br /> Inspector: Grout (from)_ �' ,, „ (to) _G_ <br /> Drilling`cig type <br /> Permit No. Auger O.D. 21 2 • 2 <br /> 4 <br /> �7 <br /> Completion - Stove pip cls (circle one) <br /> Drilling Company: Ul <br /> t , <br /> Driller: j_ T casing,. <br /> heights, <br /> Consultant ���� • <br /> Geologistx�.c�l <br /> ABOVE-GRC'UND Ci�ASST Y-80X <br /> GOh�CET�ON COMPLEIICN <br /> SPECIAL PERMIT INFO. G=nd 5urfaca <br /> Distance to sewer line SU r Y a grout <br /> Domestic well on site - (y PE) T ft, <br /> If yes, location and distance -> w <br /> wL <br /> SAMPLINGsioned <br /> Holding Temperature 4°C— <br /> Method ' ( L- = ��Pack <br /> Screening Method <br /> Tracking Sheet - n ) <br /> SPOILS <br /> I <br /> Storage Method MATERIALS(DEVELOPMENT I <br /> Contamination Noted •{y/�� <br /> Storage Location o v-1 Casing type s:i <br /> Blank coq— ft. Screen ft. <br /> SIot size (sem- 02=Q <br /> GROUTING Bags cement �r <br /> Buckets bentonite <br /> Depth to water `� Bags sand/gravel <br /> Mix Ratios s ) Filter Pack type/size <br /> installation Method::i1L V%rW_ Surge Block: -c n} <br /> Quantity Installed- Discussed with geologist: - (,' n } <br /> Tpe of method �✓�( YLc� ;gr gLC'�) <br /> EH 29 29 <br /> i <br /> l <br />