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&NITORING WELL.INSTALLATION REPO, <br /> Date:- 3 . ( I - 22, CONSTRUCTION <br /> d <br /> Premise Address: / zu-J E r",) j Total Depth �2 <br /> U .Q Screen Length (from) I � 2- (to) <br /> Well No.: C ) Filter Pack (from) 14 (to) 411 <br /> Bentonite (from) 4 I/Z (to) <br /> Inspector. M 5 Grout (frottl)T(to) <br /> Drilling rig type r-Ge '.p--77 — <br /> Permit No. I - 'CAJ Auger O.D. I.D. <br /> r' ^^ M � Completion - Stove pipe tst e o circle one) <br /> Drilling Company: t-rta.L I_,,/ <br /> Driller: -J&e �C�PI� I� e�hrt�^� casing <br /> Consultant Q,G <br /> 'D � (� I <br /> �� height <br /> —E�d't� ���IY`��Y�`��'��"'� <br /> Geologist I kr 5eln /�C��h.c ZEAS • wABOVF-GRMND T CF ROly-SOX <br /> tbkFLEMPLETK)N COMPLETION <br /> SPECIAL PERMIT INFO. Orourd Swiacy <br /> Distance to sewer line I f grout <br /> 5I� <br /> Domestic well on site - y n ) � � -4 ft. <br /> If yes, location and distance - 141/712-51 z5 t it. <br /> N M <br /> 4 = � <br /> J• o <br /> a <br /> o <br /> SAMPLING slotted <br /> 4.o aodcn _ � <br /> Holding Temperature <br /> Method IRVA UZ- <br /> Screening Method -V( D % <br /> Tracking Sheet - (y/ n ) <br /> 14I <br /> bevtei�12 <br /> SPOILS <br /> Storage MethodYV1 21C,4161� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) If �G <br /> Storage Location QA '511& Casing type <br /> qoy,f h e-;45.x- OD-6A Blank 5 ft. Screen /? ft. <br /> Slot size 0 -ozp <br /> GROUTING Bags cement - <br /> Buckets bentonite <br /> Depth to water • 5 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n <br /> Quantity Installed Discussed with geologist: - (on ) <br /> Type of method <br /> EH 29 29 Wtl1 COV'6 9 ll <br />