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ONITORING WELL INSTALLATION REPOK"i <br /> Date:- 1 - 7 - 92— CONSTRUCTION <br /> Premise Address-. ��� �GvSdG Total Depth z� <br /> Screen Length (from) I ZO (to) _ <br /> Well No,: FilterPack (from) (to) <br /> Bentonite (from) (to)ZT� <br /> Inspector: 4-f <br /> Grout (from) L . (to) <br /> Drilling rig type <br /> Permit No. ���"— �l J Auger O.D. LD. <br /> _per Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: Q.��1 ,l,lni�n <br /> Driller7M —,F <br /> casing <br /> height <br /> Consultant [�V: I _qVT <br /> _�( <br /> Geologist Agpyg GACUND <br /> CONFLETION CHCOMPLETIONPLEnON <br /> SPECIAL PERMIT INFO. mound Sumacs <br /> n grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n -ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> — m <br /> — o <br /> SAMPLING slonad <br /> s — <br /> Holding Temperature gnvw pads <br /> Method = <br /> Screening Method «; <br /> Tracking Sheet - ( y/ n ) =_ <br /> SPOILS <br /> Storage Method AU Lj MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) . /G <br /> Storage Location Casing type 0 <br /> Blank /o0t fr. Screen <br /> Slot size <br /> GROUTING Bags cement 5 <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 />