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MONITORING WELL INSTALLATION REP# <br /> Date:�13 /!1/y n ,/ CONSTRUCTION <br /> Premise Address: 69 Sh �tt 8n ) 4 Total Depth <br /> IV Screen Well No.: <br /> lu0 .Sa$ .� amu() -�dkA CG IvnNJ 'z.Pa.. Filter Pack(from) (t) <br /> Bentonite (from) (to) <br /> Inspector: _4V1"P Grout (from) (to) <br /> Drilling rig type PQ Ror-�* <br /> Permit No. Au I.D. <br /> ompletion Stove pi e(cluistie box (circle one) <br /> Drilling Company: �lt/.� \1 <br /> Driller: c ing <br /> he ght <br /> Consultant LL� <br /> Geologist (01I-� - T <br /> ABOVE-GROUND / <br /> COMPLETION CHRZ7Y-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Su fan <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n) ft <br /> If yes, location and distance - <br /> tt. <br /> — _ m <br /> = e <br /> SAMPLING slotted <br /> vection =_ <br /> Holding Temperature <br /> grsvel <br /> Method „ _ P <br /> ack <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) i/ <br /> Storage Location Casing type & p <br /> Blank ft. Screen ft. <br /> Slot size O.O/O <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to wate^Pa0 Bags sand/gravel <br /> Mix Ratios w Filter Pack type/size '2t't- <br /> Installation Method Surge Block: - 6/ n ) <br /> Quantity Installed Discussed with geologist: - (v$/ n ) <br /> Type of method <br /> EH 29 29 <br />