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UN1TORING WELL INSTALLATION REPGJ <br /> H <br /> Date: 5. 1 C12 I 1 N CONSTRUCTION <br /> Premise Address: - <br /> �tJ Total Depth �'✓ <br /> Screen Length (from) (to) <br /> Well No.: M�// Filter Pack (from) (to) <br /> M M ps Bentonite (from) (to)_ 39 <br /> Inspector. Grout (from) (to)a <br /> Drilling rig type 3 rvw px <br /> Permit No. ? — 091 o Auger O.D. 6 a I.D. 3 <br /> '/ I , - Completion - Stove pip xis' a okircIe one) <br /> Drilling CAo1mp�'anr�,,y:_ //11��K Jff��l", � t" 1�U� I� :Gr'n�}M <br /> Driller: MIM &OGV�A Vadt �J- 'o'er casing <br /> r I � height <br /> Consultant— <br /> Geologist—'D <br /> onsultant f '/ � <br /> Geologist 'D �e-tl e— K(/ a1 qk _ T <br /> E ABOVE-GROUND CHRMY-80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Gramd Su taco <br /> Distance to sewer line grout <br /> Domestic well on site - (y 3 <br /> If yes, location and distance - ft. <br /> ,Q,1D Z h. <br /> ft. _ <br /> = o <br /> SAMPLING <br /> dorsi <br /> soden <br /> Holding Temperature _ M <br /> Method (e a Z; — a'VWPa <br /> Screening Method P I ^Z;.- <br /> Tracking Sheet - (y/ n ) ; <br /> n. = n. <br /> SPOILS <br /> Storage Method 06 nrlL MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/(n <br /> j c, 7 !r <br /> Storage Location_fA"l tle Y1 N ©F U(_T Casing type <br /> Blank 4-S ft. Screen <br /> Slot size (3ZD <br /> GROUTING Bags cement <br /> t Buckets bentonite LS <br /> Depth to water �� r Bags sand/gravel 0 5 <br /> Mix Ratios/ - Q Filter Pack type/size # <br /> Installation Method e.� B Pe__ Surge Block: - ( y/ n ) <br /> Quantity Installed — Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 µ <br /> r . <br />