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6NITORING WELL INSTALLATION REPOIf <br /> Date: / eG CONSTRUCTION <br /> �(O C /1 /U! <br /> Premise Address: G Total Depth_ 7� <br /> Well No.: <br /> �q� 13 Screen Length (from) (to) <br /> /'/ Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> �/ ��7 Drilling rig type C'/'9i 75 <br /> Permit No. Auger O.D. "//Z,`/ r n , <br /> C' SConsultant Completion - Stove pip Christie boy (ct a on <br /> [� JJ <br /> _ �G✓t L �raiTCl W OUT •i75 <br /> Geologist 1p�°GL70i! <br /> SPECIAL PERMIT INFO. <br /> ABOVE-GRCUND <br /> Distance to sewer line COMPLETION CHRISTY-BOX <br /> COMPLETION <br /> Domestic well on site - (y ) —�Ground Surlaca <br /> If yes, location and distance - <br /> pfout <br /> n. <br /> ft. <br /> n. <br /> SAMPLING `+^ <br /> 0 <br /> Holding Temperature slonod <br /> Method / 1D sacdon <br /> Screening Method A Zy" <br /> Tracking Sheet <br /> SPOILS <br /> Storage Method 41/ 3 MATERIALS/DEVELOPMENT <br /> Contamination Notes - n) y //�� <br /> Storage Location Q }�. Casing type // <br /> Blank 50 ft. Screen 2-51 ft. <br /> Slot size Q 2, — <br /> Bags <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> y e, Bags sand/gravel <br /> Depth to water �� / Filter Pack type,/ '}z.e_ <br /> Mix Ratios Surge Block: -C� n ) <br /> Installation Method Discussed with geologis : T n ) <br /> Quantity Installed Type of method IOC �L <br />