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Permit No. c?e., oi,r3 <br />ft. Blank (co ft. Screen 2-0 <br />Slot size .010 <br />Bags cement +- <br />Buckets bentonite <br />01P/0 5 <br />MONITORING WELL INSTALLATION REPOts.f <br />Date: <br />Premise Address: <br />Well No.: R4t/- 44T-- / <br />Inspector: <br />Drilling Company: <br />Driller: <br />Consultani f <br />Geologist /14 WA/ <br />SPECIAL PERMIT INFO. <br />Distance to sewer line <br />Domestic well on site - ( y / n) 2 <br />If yes, location and distance - <br />SAMPLING <br />1/0 Holding Temperature C <br />Method <br />Screening Method <br />SPOILS <br />Storage Method Ok U-4A44-1 437 <br />Contamination Noted - (y( <br />Storage Location <br />GROUTING <br />Depth to water <br />Mix Ratios 37‘.1...e>0 -r- 36 sa_e_1.-- ‘Vie_64.1. <br />Installation Method <br />Quantity Installed 4 .1s- SO -0..ti,a.- /7 6-01.0 e f7°) <br />EH 29 29 <br />CONSTRUC ION <br />Total Depth <br />Screen Length (from) 9c-s (to) 6 0 <br />Filter Pack (from) T5-6 (to) 57 <br />Bentonite (from) 5- (to)56- <br />.-.•VE-GFICXJN , C4-CFIISTY-BOX <br />COMPLETION <br />(circle one) <br />Grout (from) <br />Drilling rig type 0/%4-e (3 5 <br />Auger O.D. I.D. <br />Completion - St e pipe/christie box <br />ing <br />ght <br />(to) <br />MATERIALS/REVELOPMENT <br />Casing type <br />Bags sand/gravel <br />Filter Pack type/si e 2/0-- &Oct— -of - <br />Surge Block: -y n) <br />Discussed with geologist: - n <br />Type of method CA-4-ei- 'Cad <br />Tracking Sheet -