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t'MONITORING WELL INSTALLATION REP"KT ` <br /> Date: IO A CONSTRUCTION 2 <br /> Premise Address: 12-" Total Depth <br /> Screen Length (from) 11V (to) ?zq t <br /> Well No.: Filter Pack (from) 49' (to) 7;A <br /> Bentonite (from) ZL 3' (to) Z3.3 <br /> Inspector: _�}�1M SxSlti Grout (from) Z3.3' (to) eo` <br /> Drilling rig type <br /> Permit No._ '�j 7,(o Auger O.D. 1611 <br /> Completion - Stove pi x (circle one) <br /> Drilling Company. <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist -- <br /> ABOVE-GRCUND CHRJM-80X <br /> COMPLETION COMPLETICN <br /> SPECIAL PERMIT INFO. I Ground Surface <br /> Distance to sewer line 4 JrD L grout <br /> Domestic well on site - ( y/0) <br /> If yes, location and distance - ft. <br /> �• ft. <br /> SAMPLING <br /> • _ o <br /> soden <br /> Holding Temperature _ <br /> Method �- __ R719i Pack <br /> Screening Method — <br /> Tracking Sheet - ( y/ n ) <br /> ft. <br /> SPOILS <br /> Storage Method_ 411k 6A, MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y <br /> Storage Location dVl, Casing type <br /> CG� Blank . fl' ft. Screen�0 ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite 5 <br /> Depth to water_ Bags sand/gravel lb <br /> Mix Ratios Filter Packtype/size <br /> Installation Method Surge Block: - (y/61) <br /> Quantity Installed U Discussed with geo gist: - n ) <br /> Type of method <br /> EH 29 29 /7 ' IJw°""� <br />