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MONITORING WELL INSTAILATION REPOI-,:f <br /> r W <br /> Date:ii' -3hQ 5 CONSTRUCTION <br /> Premise Address: ��� Total Depth <br /> �p Screen Length (from) �'' - (to) <br /> Well No.: 'w"0 4 Filter Pack (from) <br /> Bentonite (from) Z (to} ^— <br /> Inspector: Grout (from) (to) <br /> 1; Drilling rig type <br /> Permit No. `�1� � Auger O.D. I.D. <br /> E�. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant_ <br /> Geos st YC.�Gfi� <br /> ABOVE-GROUND <br /> COMPLEC.1ON CtiR15'IY-80X <br /> i' COMPLETIO <br /> SPECIAL PERMIT INFO. Ground surface <br /> Distance to sewer line proof <br /> i Domestic well on site - (y` Dn Z5 <br /> If yes;1�location and distance - L�T ft. <br /> -H — I <br /> SAMPLING slotted �' G <br /> soc�on = �i <br /> Holdu g Tempe tur w " __ <br /> . ack <br /> Method — Atkk �� "�P <br /> yy ' ,Screen ing Method- <br /> `Fracking Sheet - (y/ n) <br /> 45 <br /> SPOILS <br /> Storagb Method_ -e-� � d ` x. MATERIALS/DEVELOPMENT <br /> Contamination Noted (`}iA <br /> .x <br /> ti <br /> Storage Lacation ��•r. �/u�-r _ -, .. Casing type. <br /> Blank ;ft. Screen <br /> Slot size ,Old <br /> GROUTING Bags cement 9 <br /> VBuckets bentonite <br /> • Depth.Iio water ikBags sand/gravel <br /> Mix Ratios I <br /> 4- 35tIoX Filter Pack type/size �i(o <br /> Installation Method-, Surge Block: - (y nn <br /> `. . Quanti�!nstalled r' �:':c- Discussed with geologist: - (y n <br /> Type of method <br /> EH 29Ii29 <br />