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MONITORING WELL INSTALLATION RE)rT <br /> 1r e <br /> Date: �a I QS CONSTRUCTION <br /> Premise Address: I Total Depth (-0 <br /> 1 <br /> �, _ Screen Length (from) (to) <br /> Well No.: Filter Pack (from) L�(to)� <br /> Bentonite (from)—�r <br /> (to) 17` <br /> Inspector: � �� Grout (from) (to) <br /> /1 L Drilling rig type CJI I o� 5 <br /> Permit No. �-T Auger O.D. I n (' I.D. <br /> Completion - Stove pipe/ a ox circle one) <br /> Drilling Company: C c e aC 0i <br /> Driller: k— casing <br /> 'I,C" j�tTheight <br /> Consultant f <br /> Geologist P,50 V1 9 —1 —7W <br /> ABOVE-GROUND CHA7STY-80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Suian <br /> Distance to sewer line °fo I <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - n. <br /> `�.n. <br /> n. <br /> O <br /> O <br /> C <br /> SAMPLING slonad c <br /> a.c4on <br /> Holding Temperature = grava <br /> ack <br /> Method — P <br /> Screening Method <br /> Tracking Sheet - (y/n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) 11 5 cJ,e d .� y0 PVC <br /> Storage Location Casing type <br /> Blank Ljft. Screen 15 ft. <br /> Slot size <br /> GROUTING 1 Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />