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OIONITORING WELL INSTALLATION REP* <br /> Date: S & //� / � /�CONSTRUCT[ON / <br /> Premise Address: �� / ���.C�G Total Depth S <br /> / ! Screen Length (from)_ 4 (to) <br /> Well No.: �h/ _ Filter Pack (from) -5- (to)� <br /> Bentonite (from)7—R— <br /> Inspector: Grout (from)_ (to) I <br /> Drilling rig type <br /> Permit No. < / ^ �CJ TAuger O.D. /Z I. �— <br /> ��� Completion - Stove pi stie box cle one) <br /> Consultant <br /> Geologist J G✓! P (�' r// stIck-Up <br /> l✓Qep � ht .f <br /> SPECIAL PERMIT INFO. ABOVE-GRCUNO <br /> n'5 b � COMPLETION CNAISTY-80X <br /> Distance to sewer line o COMPLETION <br /> C3routd Surtact <br /> Domestic well on site - (y -- <br /> If yes, location and distance - PRO <br /> grout <br /> kyzl ft. <br /> _11ft. ft. <br /> m <br /> Ye = e <br /> SAMPLING =_ ... <br /> o <br /> Holding Twc�o <br /> emperature « "cn i _ $ <br /> n X. <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y ) <br /> z:S = <br /> ft. = 7 ft. <br /> SPOILS <br /> Storage Method /v/7S MATERIALS/DEVELOPMENT <br /> Contamination Notes - n ) rr <br /> Storage Location i/ S> Casing type <br /> Blank So h. Screen 49 <br /> S ft. <br /> Slot size 02 <br /> Bags cement <br /> GROUTING Buckets bentonite 2. <br /> s r Bags sand/gravel <br /> Depth to water �i Filter Pack type/size <br /> Mix Ratios Si 96 Surge Block: -G/ n ) <br /> Installation Method Tfrrwx _ Discussed with geologist �(�/ ltd <br /> Quantity Installed Type of method L <br /> O„ <br />