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MONITORING WELL INSTALLATION REPOnf <br /> Date:—/.25C)3 CONSTRUCTION <br /> Premise Address: 3d/f �tJ. /�e. )�PX �j /'S Total Depth `•',Q <br /> � <br /> -�, ' •, ' Screen Length (from) Z (to) <br /> Well No.: Filter Pack (from) (to �� <br /> Bentonite (from) _ 7(0 (to) A <br /> Inspector: Grout (fro <br /> 6)y�L1.0 DAu ling rig type <br /> Permit No. ger O.D. $ I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: 1 <br /> , � CC' - D-5y <br /> Driller: �/ L casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GRC JND 16'" <br /> CCMPLEiION CNAISTY-Box <br /> COMPLETION <br /> SPECIAL PERMIT INFO. <br /> 7 � <br /> Distance to sewer line <br /> Domestic well on site - (y n ft <br /> If yes, location and distance - (o ft. <br /> _ m <br /> - — a <br /> SAMPLING dotted = Z <br /> Holding Te :,a e <br /> M = ps„ei pack <br /> = <br /> Screening Method <br /> Tracking Sheet - n ) 3Z, <br /> n. n <br /> SPOILS <br /> Storage Method +A MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) 4-4LR 11.4 t' D vC <br /> Storage Location �h..�c /1 e�^� t Casing type f <br /> Blank ft. Screen—.15 ft. <br /> Slot size.O�p el <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to waterer Bags sand/gravel <br /> Mix Ratios 3 s t Filter Pack type/size <br /> Installation Method u4 u+ Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br /> /'3/ /�/3 ' 'f/ �'-$y C L 4&54/ <br />