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MONITORING WELL INSTALLATION REPO# <br /> Date: / /� CONSTRUCTION <br /> Premise Address:c�� 60 � ��� . Total Depth <br /> Screen Length (from) [3 n. (to) 3V'L- _ <br /> Well No.: /`� Filter Pack (from) 17 ti (to) t <br /> Bentonite (from) 2-vi, (to) <br /> Inspector: i Grout (from) i° (to)!oo, <br /> _ 3� Drilling rig type <br /> Permit No. ,2 Auger O.D. I 0 ' I.D. <br /> �i� Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: 1;77 casing <br /> •� �� � height <br /> Consultant <br /> IV <br /> Geologist �'�,� •- <br /> 7//, m T <br /> ABOVE-GACUND <br /> COMPLET30N CNAJSTY-80X <br /> Cwt-`nCN <br /> SPECIAL PERMIT INFO. G=ad Sufacs <br /> Distance to sewer line g(Out <br /> Domestic well on site - (y/ n ) f ft. <br /> If yes, location and distance - ;�_ <br /> ft. <br /> SAMPLING <br /> accicn —_ <br /> Holding TemperaturePack <br /> _ <br /> Method = a' <br /> vw <br /> Screening Method <br /> Tracking Sheet - (y/ n ) r <br /> SPOILS N/R <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank '?� I7i ft. Screen ft. <br /> Slot size o <br /> GROUTING Bags cement <L <br /> Bucketsbentonite I <br /> Depth to water Bags sand/gravel 24 <br /> Mix Ratios /hz.,. Filter Pack type/size z/i Z. <br /> Installation Method '(.'/-4 Surge Block: - (y/ 11 ) <br /> Quantity Installed t-'/ Discussed with geol "ist: - 0/ n ) <br /> Type of method <br /> EH 29 29 <br />