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-ONITORING WELL INSTALLA'T'ION REPOP— <br /> Date: 2� /Vove -6e/ ` � 7 CONSTRUCTION <br /> Premise Address: < � G� ��^ Total Depth <br /> Screen Length (from-) (to)-2 <br /> Well No.: <br /> Filter Pack (from) / ' __ __(to) 2t <br /> . l�f <br /> Bentonite (from) 1(e _(to),• <br /> Inspector: � Grout (from) (to) <br /> Drilling rig type <br /> Permit No._ ®�y�_SG ! Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height - <br /> G G� <br /> Consultant T <br /> Geologist �uv41 /" 'IG 'fes t<r c •� <br /> ABOVE-GROUND CHR�.M_aoX <br /> COWLET'ON COMPtE MON <br /> SPECIAL PERMTT INFO.Surisce + <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> ' m <br /> C <br /> O <br /> SAMPLING siort�d <br /> wc�on � <br /> Holding Temperaturer: <br /> -,::. VRW pack <br /> Method t> <br /> Screening Method < _ <br /> Tracking Sheet - {y/ n } .. <br /> 1�e /fie ���03� <br /> /�/�� 3/y c4Aj <br /> SPOILS �Fiy�,.�-J Jcd,'v+ti <br /> Storage Method MATERIALSZ2EVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen �• <br /> Slot size <br /> GROUTING Bags cement ` <br /> Buckets bentonite _ /" <br /> Depth to water Bags sand/gravel 171 Z <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with. geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 5'j a,, Barg r,, buYi� 6A �jdloco.;'q odav, -Tr t ze''c%'l`1 <br /> red S'u`��<J� �U �ULS Scw�(- dd•ll[✓�,,,�,(w,Ns hccv ��we( ,` pl, ,cr�� elecqrtf <br /> ✓/IBJ 40 u,r� /td' ?-y <br />