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} <br /> x MONITORING WELL INSTALLATION REPO 4 <br /> r -6:q - QO2 <br /> ba <br /> 04 z zqq <br /> oDate: sic- CO UCITON I <br /> Premise Address: �-W � Y�� �. Total Depth � <br /> M _ l a to w Screen Length (from) (to), 0 <br /> Well No. Ti M u�► Filter Pack (from)_ t _(to) 8b <br /> / Bentonite (from) Y( _(to) 5 <br /> Inspector. U7 k z. Grout (from) 38 (to) <br /> �" Drilling rig type 95 <br /> Permit No. O Auger O.D. Z"d !D''_ - I.D. <br /> / Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: f20 I7�U d n p O, V� - � casing <br /> heIg <br /> Consultant ro V& VPTA <br /> '4 <br /> Geologis �V\, ��1 TT a <br /> -N-1- : <br /> ABOVE�ACCINDC-HRt 43OX ,. <br /> mOMPL,E'TiON <br /> 'SPECIAL PERMIT INFO. x t I �' Grourd surtaco COMl�t�°TiCN <br /> Distance to �Iine /�/ { `` " 'R grout <br /> Domestic well on site (y n ) � ^ r�� { � ft. <br /> If yes, location and di a /3i <br /> — 10 c�i►@C' ft. <br /> = a t <br /> QUSiy�(!Z `�a 5�4(vri LYKsft ?'� E! 071 0r r�I� G . � • <br /> SAMPLING 43 <br /> Clay; o <br /> Holding Temperature4 <br /> Method <br /> 0 Or r 00 — { <br /> Screening MethodZip <br /> c �m <br /> Tracking Sheet (y/ n ) °w ao f = 9 a <br /> tt <br /> SPOILS •� 4 ' <br /> Storage Method No F MA RIALS/DEVELOPMENT <br /> Contamination Noted -_ / n) S p 1 T. •P /� [�0 "1 . <br /> Storage Location f lbJe�f) Casing typ <br /> - <br /> 3 •BIank fL Screen ZO h. <br /> Slot size (7 <br /> ' GROUTING Bags cement a ; <br /> � r <br /> Buckets bentonire 1 Z <br /> Depth to water � � �l � � � � •'� Bags sand/gravel 2 ►z ' <br /> Mix Ratios _ _q_- _ r/ 1� Filter Pack typ e r <br /> Installation Method. " -T2p. )YliMLV,- l/.� ,�J„'r Surge Block: n ) <br /> Quantity installed Discussed with geologist: -� n) <br /> SA" Type of metho <br /> H 29 29 <br /> ;Mal <br /> C,ro ss- <br /> "IV <br /> IV j� So. , r�v�LL'If" � Y'� <br /> l <br />