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1� ONITORING WELL INSTALLATION REPCw/ <br /> Date: ���� CONSTRUCTION <br /> Premise Address: (� � UU�'h-1� �.P1���q Total Depth �V <br /> Screen Length (from) D (to) 10 <br /> Well No.: r2c.�1' Filter Pack (from) �O (to) 9 <br /> Bentonite (from) B (to) G <br /> Inspector: M �M�'\ Grout (from) _ (to)-Q:LLt�� <br /> Drilling rig type <br /> Permit No. ���� Auger O.D. fol, I.D. 1 <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: 1!V` <br /> Driller: casing <br /> (�� -- ';�;• height <br /> Consultant -1) 117 T <br /> Geologist T <br /> ABOVE-GROUND CtiRIM43OX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) (> <br /> If yes, location and distance - to ft, ft. <br /> SAMPLING /q Tib alon&d <br /> o� saclan — <br /> Holding Temp erasure .; <br /> Method —_ P <br /> d ���� <br /> Screening Method <br /> Tracking Sheet - ( / n ) <br /> 3o ft. 30 ft- <br /> SPOILS <br /> Storage Method e� MATERIALS/DEVELOPMENT <br /> Contamination Noted it PU <br /> Storage Location Casing type ( y <br /> Blank t n ft. Screen Z ft. <br /> Slot size .02-0 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water �z Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y n ) <br /> Quantity Installed Discussed with ge gist: -P/ n ) <br /> Type of method <br /> EH 29 29 <br />