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•MONITORING WELL INSTALLATION REPG!:f <br /> Date: Q 5 7A 3 ��`�^( CONSTRUCTION <br /> Premise Address: , Q Total Depth �S <br /> A .• r Screen Length (from) 2 (to) <br /> Well No.: /vl w " Filter Pack (from) ZS (to) <br /> Bentonite (from) $ (to) <br /> Grout (from) 6 (to) <br /> Inspector: Drilling rig type f cR <br /> Auger O.D. I D <br /> Permit No. C Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: ��De <br /> ��to�- casing <br /> Driller: height <br /> Consultant Z <br /> nT— <br /> Geologist—S-4ov— <br /> AjpV -GROUND T <br /> COMPLETION COMPLE7ICN <br /> SPECIAL PERMIT INFO. Grourd Sumacs 7 <br /> 7 grout <br /> Distance to sewer line <br /> Domestic well on site - ( y n- ft. <br /> If yes, location and distance - ft' <br /> m <br /> o <br /> m <br /> SAMPLING slonad = <br /> vection `- <br /> Holding Temperature <br /> Method <br /> Screening Method P 1 = <br /> Tracking Sheet n) ZS <br /> SPOILS <br /> n <br /> Storage Method 5MATERIALS/DEVELOPMENT <br /> 5 � h �-�- (� ' <br /> Contamination Noted - (y Casing type Z1, r V(a— <br /> Storage Location dk Zr Blank ft. Screen--L5—' —f1 <br /> Slot size vw <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> (� Bags sand/gravel <br /> Depth to water Filter Pack type/size Z <br /> Mix Ratios } S Surge Block: - (y n <br /> Installation Method Discussed with geo ogist.. - (yCn <br /> Quantity Installed Type of method <br /> EH 29 29 <br /> �o - 15, 3 , uAI i/ <br />