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WONITORING WELL INSTALLATION REV <br /> Date: �i/X P Z9, Z°', CONSTRUCTION <br /> Premise Address: "6 Total Depth I �W <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) i W> <br /> Grout (from) 1( 0 (to) <br /> Inspector: Drilling rig type SDNIL <br /> Permit No. lp'fi/p0 2, Auger O.D. I.D. 5 Z <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company D"a 1 <br /> 3 casing <br /> Driller: Q�sLa/�'6'� f height <br /> Consultant –r <br /> Geologist ABOVEGROUND CHRZ'ry-BOX T <br /> CONFLETION COMPLETION <br /> SPECIAL PERMIT INFO.Surface ---- <br /> grout <br /> Distance to sewer line iw ft <br /> Domestic well on site ( ) <br /> If yes, location and distance U05tt <br /> -- I oo�' � 1J '� ��°n <br /> _ m <br /> = m <br /> _ <br /> _ o <br /> SAMPLING sloes <br /> aac5on <br /> Holding Temperature = VI18I Pado <br /> Method = -_ <br /> Screening Method — <br /> Tracking Sheet - (y/ n ) lT1n — tt <br /> SPOILSR2— <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted Casing type <br /> Storage Location <br /> Blank 1(o'4t5 ft. Screen 10 fr• <br /> Slot size <br /> GROUTING Bags cement K �A <br /> Buckets bentonite 100¢ — <br /> Depth to water Z 3.S Bags sand/gravel 35DL� <br /> Mix Ratios *t '' i Filter Pack type/size $ <br /> Surge Block: - (y <br /> Installation Me od n <br /> Quantity Installed Ill( rp��� ° r Discussed with geo ogist: - ( y o <br /> Type of method <br /> EH 29 29 <br />