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10 <br /> ONITORING WELL INSTALLATION REPO <br /> Date: I D - 5 - CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) I I (to) <br /> Well No.: Filter Pack (from) 1'�' �(to) <br /> Bentonite (from) 955 (to) 9 h <br /> Inspector. Grout (from)__T'5'_ (to) <br /> �t Drilling rig type <br /> Permit No. �q Auger O.D. I f) ! ,gyp ± <br /> Completion - Stove pi c uristie bo (circle one) <br /> Drilling Company <br /> (utR.tAmd'C-. <br /> �� casing <br /> Driller: height <br /> Consultant uyl <br /> Geologist �1e <br /> ABOVE-GROUND CNR15iY-a0X <br /> COhWLErCN COMPLEMCN <br /> SPECIAL PERMIT INFO. Ground Sutac� <br /> groutDistance to sewer line <br /> Domestic well on site 7_Ly/ n ) Ito <br /> If yes, location and distance - ti. <br /> tt. <br /> C <br /> = O <br /> SAMPLING .brad <br /> aorion —_ <br /> Holding Temperature ��A _ pavd Padt <br /> Method <br /> Screenin;Method _ <br /> Tracking Sheet - (y�/pn" ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Note (y/ n ) <br /> Storage Location 11 Casing type <br /> Blank__J_ ft. Screen <br /> Slot size D l O cdu� <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios _ Filter Pack type/size <br /> Installation Method Surge Block: - �y ' n ) <br /> Quantity Installed Discussed with geologist: - 6), n ) <br /> Type of method L ±k ML nPI Q�A <br /> EH 29 29 ~ <br />