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iVIONITORING WELL INSTAL LATION REPOA f T <br /> - i <br /> q i <br /> Date: r CONSTRUCTION <br /> 1033 W- <br /> Premise Address: Total Depth� <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) i (to) 2 j <br /> Bentonite (from) 2- (to) 6Z' ' <br /> Inspector: Grout (from) (to) o <br /> U , /� / Z� Drilling rig type �_ - <br /> Permit No. 7 / Auger O.D._ g I.D. <br /> Completion Stove pipe/Christie box (circle'one) <br /> Y <br /> Drilling Company: `• -`; <br /> Driller: casing <br /> r{ <br /> height <br /> Consultant <br /> -Geologist <br /> „ABOVE-GROUND <br /> C?�Ft65TY-$OX s <br /> ,. � K,�� -, .,.'•"= �� _ " �`�'""' , r e ```COMPLETION' i <br /> + COMPCEnON <br /> SPECIAL PERMIT INFO. '*..� ',� �� ' '` `'1 :Groff id Surface <br /> .Distance to sewer line 3�^tib �'� •-grout <br /> ,:. <br /> Domestic well on site - (y n <br /> If yes, location and distance - qZ <br /> j�' <br /> • $� - <br /> �tl`Y�!, ,t ,. - - s - _.V.r- �.� i.--•-�.. "• - -.. ,- .� �t.�..--- ... .. - o - -rte - - -- �- �-� 1 <br /> r <br /> SAMPLING ` l"¢ w �k. .XE �tr ,r� slotted <br /> v:s.5''M.""` ...+ � i �:�a. .�J'�u'* yW:y `kA'r'•'�•t`°."� '' " `q'.`'��"�-"'�iiG'iQfl :� � �' <br /> Holding Zernperature " <br /> W <br /> Method i n� ,,�` ' �; ,: _ :sig P <br /> ack <br /> + Screening`Methad �'}_ k c P•ivy k�; . - _ _'- <br /> Tracking Sheet" (.Y.- n)--, - <br /> J)-- V. <br /> A SPOILS y` >o r r „ ; mow 1 <br /> Storage Method'I"" !!r>;5 MATERIALS EVELOPMENT <br /> Contamination Noted = <br /> . Dn ) �r "' <br /> Storagelocation '' u� p ,r Casing type 2 E_ scl <br /> Q A .s ;: 'a te ' Bla:fik `wfC: ' .'Screen. I t. <br /> _.y , 's.�.�:..r€ a• " ter * q:t�*. '.' Slot size .01tD <br /> GROUTING Bags cement "' <br /> Buckets bentonite + <br /> " y. y Depth toawater Bags sand/gravel _ <br /> Mix patios Ax� Filter Pack type/size Yh <br /> Installation Method Surge Block: - (yPn .. k <br /> . ' <br /> Quantity.Installed ,4 µ ; Discussed with ge >(y%n) _ `f K <br /> V` Type of-method N <br /> .' EH 2929 <br /> V4 J.V. <br /> MR/ <br /> 1 <br />