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1CIUNITORING WELL INSTALLATION REPOnY <br /> Date: 4A - 2,W w CONSTRUCTION 2 <br /> Premise Address: /I/ Cu Total Depth i5 <br /> J Screen Length (from) (to) <br /> Well No.: Cl ^ `C Filter Pack (from) (to)� <br /> Bentonite (from) I/ (to) S <br /> Inspector: Grout (from) 5 (to) <br /> / Drilling rig type 6--C 5 <br /> Permit No. 0 d Auger O.D. I.D. <br /> Co o - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: y casi g <br /> /D Zheig <br /> Consultant �i�a � /� � <br /> Geologist <br /> y�or Ag0V -GROUND <br /> COWP�bN % <br /> SPECIAL PERMIT INFO. Ground SuAxs COMPLETION <br /> Distance to sewer line <br /> ? 6grout 94 <br /> Domestic well on site - ( y/ n) T — �- h '`G O <br /> Ifes, location and distance - 3 <br /> TF' <br /> Y EF <br /> a <br /> P <br /> O <br /> C <br /> SAMPLING slotted <br /> sarion <br /> Holding Temperature <br /> Method = graW pack <br /> Screening Method <br /> Tracking Sheet - (y/n ) 1 G <br /> J J ft. ft. <br /> SPOILS ( '✓DD `-- <br /> Storage Method �` t `�� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n �i S PU" <br /> Storage Location Casing type +P <br /> IP <br /> ' JK' h. Screen 1•o h. <br /> Slot size C>21-) <br /> GROUTING Bags cement <br /> Buckets bentonite I <br /> Depth to water Bags sand/gravel 11 '> 2-41�b� <br /> Mix Ratios Filter Pack type/size 'J f (oQ�L •6 . <br /> Installation Methda Surge Block: - (y n') <br /> Quantity Installed Discussed with geo ogist: - ( y <br /> Type of method <br /> EH 29 29 <br /> �TIUM17P <br /> INce #/a-,) D6.� z� �s <br />