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MONITORING WELL INSTALLATION REPOnf <br /> Date: C,(/ _ CONSTRUCTION <br /> Premise Address: (4 d " G�a Total Depth <br /> Q Screen Length (from) (to) S <br /> /e <br /> Well No.: �L— Filter Pack (from) (to) 13 <br /> Bentonite (from) .(to) 12- <br /> Inspector: <br /> ZInspector: Grout (from) 2 (to) a <br /> Drilling rig type GM6 85 <br /> Permit No. Auger O.D. 10 I.D. (o <br /> `C Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: Q <br /> Driller: �aA-jd casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND CHMM-acx <br /> COMPLETZN LEi1C <br /> SPECIAL PERMIT INFO. //� c.• •- Grund S atxa <br /> Distance to sewer line ? I C,o'-` .� -�""'` gra <br /> Domestic well on site - (y (L g• <br /> If yes, location and distanc - 3 IL <br /> eft. <br /> = m <br /> — o <br /> — m <br /> _ c <br /> — o <br /> SAMPLING dotted <br /> tac9on <br /> Holding Temperature Its <br /> _ gravel Pads <br /> Method = <br /> Screening Method r` <br /> Tracking Sheet - (y/ n ) <br /> CNd�S <br /> SPOILS <br /> Storage Method e ! MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n (f <br /> Storage Location L Casing type <br /> Blank $. Screen /O ft. <br /> Slot size •O 10 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water A Q, / <br /> Bags sand/gravel O <br /> Mix Ratios Filter Pack type/size 17 <br /> Installation Method Gu Surge Block: -0 n ) <br /> Quantity Installed Q Discussed with geolo •s[: - n ) <br /> Type of method f �'� /v C,t✓y'� <br /> EH 29 29 �0 -^ <br />