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%,OONITORING WELL INSTALLATION REPG,,OOo <br /> Date: l' b— .� �) ( I CONSTRUCTION <br /> IID �1 � q <br /> Premise Address: t itn Total Depth I� <br /> p Screen Length (from)( 6 <br /> Well No.: V s T I Filter Pack (from) _( - <br /> Bentonite (from) ) SZ �peQ <br /> Inspector. Grout (from)gh� ' ) <br /> Drilling <br /> Permit No. 6 D '+1 7 -) Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: CAA,,, casing <br /> ��� <br /> Consultant C � �� height <br /> VYA <br /> Geologista9^ <br /> ABOVEGROUND Ct6if5TY80X <br /> COMPLEf10N COMPLEMN <br /> SPECIAL PERMIT INFO. Ground Sudan <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - <br /> ft ft. <br /> v _ m <br /> SAMPLING slored <br /> axicn — <br /> Holding Temperature._. 1r ) <br /> Method <br /> Screening Method I. ` <br /> Tracking Sheet - (y/ n ) <br /> ft. = tt <br /> SPOILS <br /> Storage Method 9 - MATERIALS/DEVELOPMENT <br /> Contamination Noted • / <br /> Storage Location az';� Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water �75 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 />