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MONITORING WELL INSTALLATION REPC.OF <br /> Date: 41 �I�( d� CONSTRUCTION <br /> Premise Address:,(-;�Gl Total Depth 1 Z <br /> rrnn,w, Screen Length (from) 3 (to) l <br /> Well No.: Yv` Filter Pack (from) :3?_ (to) 1!5 <br /> �p r Bentonite (from) 1� (to) 1 � <br /> Inspector. bwt'lm i t'i� l� y�' ��1 fv�'' Grout (fr6e) 1 !2 (to) r c <br /> Drilling rigye_ D�o.(Permit No. Zf�`- � -` Auger O.D. i . <br /> Completion - Stove pipe chrisue box ircle one) <br /> Drilling Company:��-E' OYI-11 <br /> Driller: .rC W1 aicy I�'�C ^' casing <br /> he; <br /> Consultant �- <br /> Geologist A80VE-GROUND <br /> COMPLETION C40MPLEMN <br /> COMPLr�71CN <br /> SPECIAL PERMIT INFO.Surtacs <br /> If <br /> Distance to server line <br /> N 1 grout <br /> Domestic well on site - (y/n) ft. <br /> If yes, location and distance - ft. <br /> — a <br /> SAMPLING stored c <br /> sacicn = .3 <br /> Holding Temperature = <br /> 97mavW Facie <br /> Method <v - <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> ft <br /> SPOILS � ,\ i v�nd.1 1„ras �'"'�� C"' d" <br /> 0,,,7.sc.-j Oe vr-si'n' MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/n) Casing typeVC S <br /> Storage Location Blank �� ft. Screen ft- <br /> Slot size L C::,2� <br /> rj <br /> GROUTING Bags cement -- <br /> Buckets bentonite <br /> Bags sand/gravel '�' <br /> Depth to water ZZ ` o-e^�r-` 'b' a 2 <br /> Filter Pack type/size <br /> Mix Ratios �- Surge Block: - (y/ n ) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity Installed_ Type of method — <br /> EH 29 29 <br />