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iviONITORING WELL INSTALLATION REPOr,, <br /> Date: O '30 �� CONSTRUCTION <br /> Premise Address: / `�7' 7 S �� Total Depth 7 <br /> Screen Length (from) (to) <br /> Well No.: vV D Filter Pack (from) :F- (to) <br /> Bentonite (from) (to) 3 <br /> Inspector: Grout (from) (to) <br /> 7Drilling rig type <br /> Permit No. 5 7�12, Auger O.D. 8 I.D. ¢ <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: �"� i � / casing --- <br /> (� C/ I 7776L height <br /> Consultant �s \ <br /> Geologist ��7L� ._ <br /> ABOVE-GROUND CHRLM-BOX <br /> COMPLETION COMP <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line �-�d grout <br /> Domestic well on site - ( yn [ ft. <br /> If yes, location and distance - ft. <br /> p <br /> C <br /> SAMPLING slottedtj- <br /> = c; <br /> secton <br /> Holding Temperature gavel p- <br /> Method <br /> Screening Method <br /> Tracking Sheet (y/ n ) <br /> SPOILS /� <br /> Storage Method �5 7 C'q 2= MATERIALS/DEVELOPMENT <br /> Contamination Note—d—( yyn� I ve <br /> Storage Location dh A`%T-� Casing type r - <br /> Blank ft. Screen ft• <br /> of Slot size •Ib�GYd <br /> GROUTING '•Bags cement 9 t f 6 t <br /> e Buekets bentonite 3 2 O <br /> Depth to water J . Bags sand/gravel <br /> Mix Ratios Z 3 / .J.f.�tyt'-35 Filter Pack type/sizeInstallation Method Surge Block: - (y n <br /> Quantity Installed = 4*0 Discussed with geologist: - (y V <br /> Type of method <br /> EH 29 29 <br /> 6��6A 9 cT <br />