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_ t <br /> MONrroRjNG WELL INSTALLATION RF'-KT <br /> If CONSTRUC7110 <br /> Date: <br /> k } ,�� �c�, Total Depth g C7 (to) 9 c� <br /> premise Address: Screen. Length (from) <br /> r <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) — <br /> [' [r Grout (from) <br /> Inspector. Drilling rig type I.D. <br /> Auger O.D. <br /> Permit No. Completion - Stove pipe/chri.stie box (circle one) <br /> Drilling Company'_�� <br /> C <br /> - � Casia9 <br /> Driller. cc � he,'9h1:. , <br /> Consultant <br /> --�—L2—'---/ PTA <br /> ji <br /> Geologist v 1lSCY�-.SROUiVD q,ASSi^'-3rJX <br /> C,..CW ET;CN C-1-Vvf?L-i 7CN <br /> C,ccurld 5csfaca � <br /> SPECIAL PERMIT INFO. � <br /> Distance to sewer line �- <br /> Domestic well on site - ( y <br /> if yes, location and distance - - ` <br /> _ O <br /> a' <br /> SA_WLING EacCn� a <br /> aacn '� <br /> ?-folding Temperature <br /> Method <br /> Screening Method = <br /> Tracking Sheet - C y/ n ) <br /> �� ♦ _ tL <br /> SPOILS <br /> Storage Method MATERILAI,S/QEVELOPMENT <br /> Contamination Noted - {y Casing type C <br /> Storage Location Blank fn Screenf- <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter pack types e <br /> Installation Method Surge Block- - A// n ) <br /> Quantity Installed Discussed with 1ogist: - C y/ a} <br /> Type of method <br /> EH 29 29 <br />