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MONITORING WELL INSTALLATION REPOtc f <br /> Date:_0 ���> lkdrx) CONSTRUCTION <br /> Premise Address:� ( Total Depth 91 <br /> �j <br /> —� Screen Length (from) U (to) <br /> Well No.: As- 3 3 Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) _(to) <br /> DO T� Drilling rig type 614 E <br /> Permit No. T Auger O.D. I.D. ' <br /> Drilling Company: <br /> /J� Ze Completion - Stove pipesite box c ' (circle one) <br /> 11 ( <br /> Driller: .4 f /N V casing <br /> `vi height <br /> Consultant <br /> Geologist � � "T - T <br /> A80VE-GR0UND CHRISTY80X <br /> COWLEiION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line � O 11 grout <br /> Domestic well on site - (y 40 T n <br /> If yes, location and distance - <br /> J fl. <br /> 0 <br /> — o <br /> SAMPLING / slottad = c <br /> on <br /> Holding TemperaturGrxUr = V'W <br /> Pack <br /> Method <br /> :c = <br /> Screening Method <br /> Tracking Sheet - n) 90 <br /> rt. — n <br /> SPOILS 9 / <br /> Storage Method 61 MATERIALS/REVELOPMENT <br /> Contamination Noted - y <br /> Storage Location 7o_14_4_� Casing type c/t <br /> Blank ft. Screen S h• <br /> Slot size 02.0" <br /> GROUTING Bags cement <br /> Buckets bentonite cce/•� 3V <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size 3 <br /> Installation Method Surge Block: - (y <br /> Quantity Installed Discussed with geo ogist: - (y<D <br /> Type of method <br /> EH 29 29 <br /> �-ploy ,�s 33 <br />