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�NITORING WELL INSTALLATION REPOP– <br /> L <br /> Date: /I�/ –! CONSTRUCTION <br /> Premise Address: /L� C y Total Depth /r j <br /> / Screen Length (from) (to)_ <br /> Well No.: /�� /� Z , M W Filter Pack (from) /�� (to) Z <br /> Bentonite (from) 3 ' (to) / <br /> Inspector: Grout (from) <br /> c Drilling rig type <br /> Permit No./ Z Oy0 Auger O.D. /D' <br /> Completion - Stove pipe/ stie box (circle one) <br /> Consultant �U� � JT— <br /> Geologist_ � T°ticic-up <br /> SPECIAL PERMIT INFO. <br /> ABOVE-GROUND <br /> COMPLETION CHRISTY43OX <br /> Distance to sewer line COMPLETION <br /> Domestic well on site - ( y n-1 Ground SuA°ca <br /> If yes, location and distance = Qt1o,, <br /> ft. <br /> ft. <br /> O <br /> SAMPLING <br /> — o <br /> Holding TSnperature 7 totted <br /> Method /-)A4,4-, r. °aCon K; <br /> Screening Method ( = Qnwl pack <br /> Tracking Sheet n) is _ <br /> tt. _ /S� tt. <br /> SPOILS <br /> Storage Method �c71 Q u� MATERIALS/DEVELOPMENT <br /> Contamination Notes -, 1 L , ( g� ,/ „ <br /> Storage Location MVL�I�. [fJ[ Casin e (JCi `C <br /> Blank S ft. Screen ZL2 ft. <br /> Slot size G/D <br /> Bags cement <br /> GROUTING Buckets bentonite / C <br /> Bags sand/gravel . S <br /> Depth to water ' �� Filter Pack type e 7�i z� <br /> Mix Ratios Surge Block: ( y)/n ) <br /> Installation Method 1W. 0 ze,a Discussed wi geologist: -�/ <br /> Quantity Installed L Type of method Secit�i DA i <br /> r � <br />