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'--MONITORING WELL INSTALLATION REP6V,)r <br /> Date: !� " r CONSTRUCTION <br /> Premise Address: C -SZF— Total Depth V6. <br /> ' r` Screen Length (from) (to) <br /> Well No.: V_ O ` ' Filter Pack (from) (to)� <br /> Bentonite (from) (to) f `L <br /> Inspector: �C3 '� Grout (from) (to) <br /> Drilling rig type N6 <br /> Permit No. ' �`f'!I� Auger O.D V, 2� <br /> j Completion - Stove pip(christie box circle one) <br /> Consultan <br /> Geologist tk*-up <br /> 11T <br /> SPECIAL PERMIT INFO. ABOVE-GROUND <br /> COAPt.ETfON CIiR1STY-80X <br /> COMPLETION <br /> Distance to sewer line /ice <br /> Ground Surface <br /> Domestic well on site - (y <br /> If yes, location and distance - grout <br /> . ft. <br /> ft. <br /> Y:i -• 0 <br /> 9•' A <br /> SAMPLING w — <br /> a o <br /> Holding Temperature slcit*d _ c <br /> Method sacdon x` <br /> l/ — <br /> Screening Method ; =_ gravel pack <br /> Tracking Sheet - y n) <br /> fL <br /> SPOILS <br /> Storage Method L MATERIALS/DEVELOPMENT <br /> Contamination Notes - y n ) IF <br /> Storage Location 6,AJ S/<— Casing type ;64 G' <br /> Blank /J ft. Screen <br /> Slot size O o <br /> Bags cement _ s <br /> GROUTING Buckets bentonite Cl�i <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios G Surge Block: - (y <br /> Installation Method /! Discussed with geologist: - ®/ n ) ft�J <br /> Quantity Installed 6D 4&t-1 Type of method yr <br />