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"%!KONITORING WELL INSTALLATION REPCx,.,., <br /> Date: ��•z ©�G/f <br /> CONSTRUCTION <br /> Premise Address:_ ��-' S � �,� Total Depth <br /> /Z Screen Length (from) z (to) S6 <br /> Well No.: f Filter Pack <br /> (from) (to) 3"� <br /> Bentonite (from) s % (to) s/ <br /> Inspector: Grout <br /> (from) s (to <br /> Drilling rig type <br /> Permit No. Auger O.D._ /_ I.D. y <br /> Consultant Q ✓\ Qv S S e Completion - Stove pipe/christie box (circle one) <br /> Geologist C K A1;,q/4t - joa-o <br /> P <br /> I M T <br /> 711SPECIAL PERMIT INFO. 111 , T <br /> ABOVE-GROUND <br /> �� <br /> Distance to sewer line COMPLETION CHRISTY-BOX <br /> COMPLETION <br /> Domestic well on site - (y/(0 Gmund S <br /> If yes, location and distance - grout <br /> ft. <br /> SAMPLING = o <br /> c' c <br /> p <br /> Holding Temperature 2106d _ Z <br /> Method section — <br /> Screening Method <br /> Tracking Sheet - (y P <br /> SPOILS <br /> Storage MethodS r r�Gr'�p� ` MATERIALS/DEVELOPMENT <br /> Contamination Notes - (y/ n ) "Y' <br /> Storage Location app? S.`A- Casing type l - 0i <br /> Blank —ft. Screen `S U ft. <br /> Slot size C.2 --- <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water �3• _ �� fir' — ��s'� Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/ n ) <br /> Installation Method Discussed with geologist: - n) <br /> Quantity Installed Type of method <br />