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*7110NITORING WELL INSTALLATION REP0tZ r' <br /> Date: P CONSTRUCTION <br /> T <br /> Premise Address: 12-67 Total Depth <br /> Screen Length (from) (to) <br /> Well No.: i S/Z Filter Pack (from) (to) — <br /> Bentonite (from) 3(' (to) 3�? _ <br /> Inspector: Grout (from) (to) <br /> �^ y� Drilling rig type G7-b- 4&4,e,*5T <br /> Permit No. /� 07/ Auger O.D. 4 I.D. 441 <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> Consultant <br /> G height <br /> Geologist &z4T <br /> ABOVE-GROUND <br /> COWLETCN CNAISTY-80X <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line 100 grout <br /> Domestic well on site - ( y/ n ) 3)—. ,. <br /> If yes, location and distance - <br /> ft. <br /> ft. - <br /> = m <br /> — r <br /> �• c <br /> SAMPLING <br /> slotted � c <br /> 9G _ s sac7�on <br /> Holding Temperature ,O <br /> Method _ <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> 1L_ft. t — ft. <br /> SPOILS <br /> Storage Method �� In�� MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n } // � /YC <br /> Storage Location (� .wee Casing typ f <br /> Blank Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> _ Buckets bentonite / 7X2 d <br /> Depth to water 1S Bags sand/gravel <br /> Mix Ratios Filter Pack type/size 2 <br /> Installation Method Surge Block: - ( n ) <br /> Quantity Installed Discussed with geo gist: - (y n ) <br /> Type of method <br /> EH 29 29 <br /> sv�-//' 6 r/1.5/z �� <br />