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'°50NITORING WELL INSTALLATION REPO <br /> Date: ! O 7 CONSTRUCTION <br /> Premise Address: Sy?/ / - -9f, A/ Ot- Total Depth <br /> ,,/'Q Screen Length (from) (to) <br /> Well No.: 1 t Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to)_ <br /> OSB �- 3 Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Copany: 4D lo <br /> Completion - Stove pipe/christie box (circle one) <br /> Driller: Gam"l casing <br /> ,gyp height <br /> Consultan <br /> Geologist /"�5- � G � •- �—� <br /> ABOVE-GROUND CNG1M480X <br /> COMPLETfCN COMPLETION <br /> SPECIAL PERMIT INFO. urf <br /> Distance to sewer line ? �5 °r grout <br /> Domestic well on site - (y/ n ) y o <br /> ft' <br /> If yes, location and distance - <br /> a <br /> SAMPLING �Iotted <br /> Holding Temperature / _ VayW Pack <br /> Method — <br /> Screening Method <br /> Tracking Sheet - y n ) — <br /> gd ft = tt. <br /> SPOILS xx <br /> Storage Method ✓g MATERIALS/DEVELOPMENT <br /> Contamination Noted - y ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <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 /> �s n <br />