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7 1ONITORING WELL INSTALLATION REPCMA <br /> i <br /> DaterT�.. ''/9 p �� CONSTRUCTION <br /> Premise Address: /0 �✓�% >�• `� Total]Depth old , <br /> �� ���5-�� . Screen Length (from) (to) <br /> Well No : Filte Pack (from) . (to) <br /> Bentonite- --'(from):• _ (to).__3. 2 <br /> Inspector: Y _ Grou"t (from) L(to) <br /> ,o Drilling rig type Gs�-V <br /> Permit No. C nAuger O.D. I.D. <br /> 4 - •` Completion -Stove pipe/christie box (circle one) <br /> .Drilling Company: /PrS� _ 5 �9 •P 1 <br /> Driller: casing <br /> Sf <br /> height <br /> Consultant <br /> _ e <br /> Geologist s 1 - r M <br /> ABOVE-GROUND <br /> . _ ♦ �y ::_».- r.. COAFLETION cHRISiY ON <br /> SPECIAL PERMIT INFO Ground Surtxs <br /> Distance to sewer line .49 �I�,"=- <br /> Domestic well on site - (y <br /> If yes, location and distance - ft <br /> .-SAMPLING'` <br /> t <br /> Holding Temperature y) VAY91 Ga. <br /> Method <br /> Screening Method_ <br /> Tracking Sheet (y/n ) too <br /> fi <br /> .1/oft. ft <br /> t . <br /> SPOILS - <br /> Storage Method ." M MATE-RIALS/DEVELOPMENT <br /> Contamination Noted- (y n <br /> Storage Location / Casing type ':� 16 <br /> Blank' ft. . Screen 20 fr. <br /> • Slot size . 070 <br /> GROUTING Bags cement lht /N <br /> n <br /> If Buckets bentonite_ <br /> Depth to water A. Bags sand/gravel <br /> Mix Ratios 1 i 9 �n� f U0SAP Filter.Pack type/size 3 <br /> Installation Method 51AO Surge`_Block: - (y)n ) <br /> Quantity Installed Discussed with geolpgist: - n ) <br /> k Type of method <br /> EH 29 29 r 3 <br />