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ONITORING WELL INSTALLATION REPO* <br /> Date: CONSTRUCTIiON <br /> ,�[�, <br /> Premise Address: /" Uar� �`� ""` Total Depth l 63 <br /> ��, / U Screen Length (from) (G,� (to) I`Fb <br /> Well No.: ` Filter Pack (from) i tin (to) i 3 b <br /> Bentonite (from) 1 3 L- (to) I} L <br /> Inspector. Grout (from) z (to) <br /> q Drilling rig typed - L <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: I�I�l�_l� <br /> Driller. ��r casing <br /> T height <br /> Consultant t�2�t —QV <br /> Geologist I/�t�. "�. T <br /> ABOVE-GAMND Ctffi M-BOX <br /> COMPLETION COMPLEnCN <br /> SPECIAL PERMIT INFO. Ground SWC <br /> Distance to sewer line �� �� t S Orart <br /> Domestic well on site - CDA� h <br /> If yes, location and dista c - j I g. <br /> = r2 <br /> SAMPLING tilA slorod _ E <br /> soden <br /> Holding Temperature - qpm <br /> Method <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) <br /> i bo n. r. = i � • n. <br /> SPOILS <br /> Storage Method - tl MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( / n <br /> Storage Location (S-0 NY �w cGhl Casing type U <br /> Blank 1 FO ft. Screen Z c> ft. <br /> Slot size 109 <br /> GROUTING Bags cement <br /> Buckets bentonite 2,15- <br /> Depth <br /> 5Depth to water Bags sand/gravel <br /> Mix Ratios M.z—f' 0A"j_✓C Filter Pack type/size_ <br /> Installation Method o ti,�. Surge Block: - a/ n ) <br /> Quantity Installed Discussed with geologist: - C} / n ) <br /> Type of method <br /> EH 29 29 <br />