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MONITORING WELL INST TIZREP(,..04 <br /> Date: J <br /> // CONSTRUCI70N <br /> Premise Address: ? T f CJU" �b Total Depth <br /> yWell No. Screen Length (from) (to) <br /> • Filter Pack (from), (to) <br /> Inspector: L Bentonite (from) (to) <br /> Grout (from) {to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/cluzstie box (circle one) <br /> Driller. casing <br /> height <br /> Consultant <br /> _�Z�. �LZ 7r7 TGeologist T <br /> &!2;oi _Q <br /> ABOVE-GROUND CNR15'fY-8CX <br /> 00I�f ETiON COMPLETION <br /> SPECIAL PERMIT INFO Ground Swiace <br /> Distance to sewer line Grout <br /> Domestic well on site - {y/n) <br /> If yes, location and distance - <br /> r....r...it. <br /> tL <br /> V Y <br /> SAMPLING = s <br /> slo6d <br /> lOCICA r <br /> dry: <br /> Holding Tem er tore <br /> �OL — <br /> Method _U I — 9r1V9Ipack <br /> Screening Method <br /> Tracking Shcet (y n ) <br /> n. <br /> SPO moi° 9?,6 <br /> V 0 <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted - {y/ n) <br /> Storage Location Casing type <br /> BIank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> ? Buckets bentonite <br /> Depth to water> r Bags sand/graveI <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 <br />