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•VIONITORING WELL INSTALLATION REPO <br /> q / <br /> Date: CONSTRUCTION <br /> Premise Address: `J�l ted/ Total Depth �J <br /> 9 2 Screen Length (from) (to) <br /> Well No.: T Filter Pack (from) (to) <br /> Bentonite (from) <br /> Inspector: Grout (from) (to) C7 <br /> �Rf 002 363 �S�or�l'�� D glingrigtype <br /> Permit No. Auger <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:_ ' <br /> Driller: casing <br /> / height <br /> Consultant 7T �n <br /> Geologist �0��/rL 7F <br /> ABOVE GROUND <br /> OO&FLEfION CFfAISTY-BOX <br /> PLEnCN <br /> SPECIAL PERMIT INFO. Ground Su face <br /> r <br /> Distance to sewer line *�5U grout 1 �� <br /> Domestic well on site - (y i tt <br /> If yes, location and distance - <br /> ft. <br /> tt. <br /> — m <br /> - m <br /> SAMPLING <br /> slotted = c <br /> sec5cn <br /> Holding Tempgrature grsvol Pack <br /> Method C4 <br /> Screening Method <br /> MMethod <br /> Tracking Sheet - n ) / <br /> SPOILS <br /> Storage Method 55 MATERIALS/DEVELOPMENT <br /> Contamination Noted - y „ <br /> Storage Location ! t 24-AA Casing type Z Pt�c <br /> Blank ft. Screen 20 ft. <br /> Slot size -AZO <br /> GROUTING Bags cement <br /> q Buckets bentonite <br /> Depth to water ^ 3/ Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y <br /> Quantity Installed Discussed with geo n ogist: - ( y4�D <br /> Type of method <br /> EH 29 29 <br />