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.�iGNITORING WELL INSTALLATION REPOnT " <br /> Date: ,6 CONSTRUCTION <br /> Premise Address: lo /j, Gl/1,1.JeA Total Depth R <br /> Screen Length (from) (to) <br /> Well No.: �' Filter Pack <br /> (from) (to)_ 6g <br /> Bentonite (from) (to) 6 6� <br /> Inspector: Grout (from) (to)_ 35, <br /> Drilling rig type /lL <br /> Permit No. ��� Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: LTX C <br /> Driller: 1 casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CtiFItSTY-80X <br /> COMPLETION <br /> SPECIAL PERT INFO. Ground S <br /> MI <br /> 7 <br /> Distance to sewer line <br /> Domestic well on site - ( y ft <br /> If yes, location and distance - <br /> -� <br /> ft. <br /> ft. <br /> = m <br /> SAMPLING slotted v = <br /> sacron — <br /> Holding Temperature = P <br /> ack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) r. _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ ) ^l' <br /> Storage Location O� /� --t G 1�'^ Casing e 2`� S11^ <br /> Blank ft. Screen <br /> Slot size . D (C) <br /> GROUTING Bags cement <br /> Buckets bentonite -TfZ30 <br /> Depth to water = Bags sand/gravel 4 Clio <br /> Mix Ratios t 91f )( IL ✓ Filter Pack type/size 2 l <br /> Installation Method Surge Block: - (y('-�) <br /> Quantity Installed I_5uL Discussed with geo ogtst: - ( y'l_J <br /> Type of method <br /> EH 29 29 <br />