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&ONITORING WELL INSTALLATION REPIO <br /> Date: V l o OZ CONSTRUCTION <br /> Premise Address: 0 S G �`� Total Depth <br /> // Screen Length (from) (to) <br /> Well No.: 17J� 1 L�m m13 Filter Pack (from)—(to)— <br /> Bentonite <br /> from) (to)Bentonite (from) (to) <br /> Inspector: &tkn� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant ��S <br /> 7271 <br /> Geologist/,vL � •- <br /> ABOVE-GRCUNO CIiAiSTY BOX <br /> CCMPLETICN LA116 COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sumacs —r—� <br /> Distance to sewer line 4y�-- grout 4e <br /> Domestic well on site - (y/ n ) � III <br /> ft. <br /> If yes, location and distance - b <br /> � m <br /> 0 <br /> C <br /> SAMPLING 10 slotted _ c <br /> asc on — <br /> Holding Temperaturegrav= d pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS I <br /> Storage Method 1��77�h�. w NC 3 MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ^A I f <br /> Storage LocationCasing type <br /> Blank ft. Screen ft. <br /> Slot size 0.C7�V 44 O. 10� <br /> GROUTING Bags cement <br /> / Buckets bentonite <br /> Depth to water (, Bags sand/gravel 43 tk ti (S <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (yn-) � <br /> Quantity Installed Discussed with geologist: - t' / n ) <br /> Type of method <br /> EH 29 29 <br />