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it <br /> iONITORING WELL INSTALLATION REPC <br /> N <br /> Date: CONSTRUCTION I <br /> Premise Address : 1 �p' 1 b Hvv)+E A I Total Depth L <br /> 5\� yV �W 5B i� Screen Length (from) 5 (to) <br /> „ _ <br /> Well No. : J `r Filter Pack (from) tl5 (to) 2 07i <br /> Bentonite (from) 23 (to) ZI <br /> Inspector: 1I "!\ / Grout (from) Zl (to) o <br /> Drilling rig type <br /> Permit No. Auger O.D. �� I.D. <br /> UW h1 � L � U15 Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> Drilling Company: 'r <br /> flEJbwt casing <br /> LU rl height <br /> Consultant "- C��✓1 •� <br /> Geologist -✓vt LiACtVti - T <br /> ABOVE-GRCUND CHRISTY-BOX <br /> COA�LEiION COMPLETION <br /> SPECIAL PERMIT INFO. tt 11 Ground Surlaca <br /> Distance to sewer line V &tZ no 14.; YJ grout <br /> Domestic well on site - ( y / ) 2l ft <br /> If yes, location and distance - <br /> ft. <br /> SAMPLING slotted <br /> aacdon <br /> Holding Temperature JCL.04 L) CL <br /> Vavgl pack <br /> Method \ Le- Ll -C:5 k PX•U� s1-Pcl LV, <br /> Screening Method •ZI h <br /> Tracking Sheet - (&O n ) 17orLA <br /> �n. = n. <br /> SPOILS <br /> Storage Method 15drums iae)(L Yif MATERIALS/DEVELOPMENT <br /> Contamination Noted - Dyy / n `PV C <br /> Storage Location [ A04n.cztyf prooel^ 1t'}i SCasing type <br /> 4V\ Ced IJIIP(l j Yv�. l is OW 1-C4 � Qa� �v4vIQ t Blank 6E Screen ;e O ft. <br /> Slot size O 2b <br /> GROUTING Bags cement <br /> n � Buckets bentonite <br /> Depth to water �G8 / Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y / n <br /> Quantity Installed Discussed with geologist: - (0/ n ) <br /> Type of method <br /> EH 29 29 <br />