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,ANITORING WELL INSTALL-A N REPO <br /> Date: G/Igz 7 CONSTRUCTION <br /> Premise Address: dY o ed-I., SV _ Total Depth <br /> /(� Screen Length (from) (to) <br /> Well No.: Filter Pack (from)—(to)— <br /> Bentonite <br /> from) (to)Bentonite (from)—(to)— <br /> Inspector: <br /> from) (to)Inspector: L Grout q (from) (to) <br /> Drilling rig type <br /> Permit No. �� .>U!KZ— Auger O.D. I.D. <br /> /�� Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: f 2, casing <br /> height <br /> Consultant -`� <br /> T <br /> Geologist ABOVE•GROUNO <br /> OX <br /> COMPLETION CCOMPLETION <br /> SPECIAL PERMIT INFO. Ground Sur('n <br /> Distance to sewer line S b grout <br /> Domestic well on site - (y tt, <br /> If yes, location and distance - tt- <br /> _tt. <br /> = m <br /> _ o <br /> — m <br /> _= c <br /> SAMPLING slotted <br /> - sedon =Holding Temperatur = Qnvel pack <br /> Method = _ <br /> Screening Method <br /> Tracking Sheet n ) (� <br /> �ft. <br /> tt. <br /> SPOILS / <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted • n ) t( <br /> Storage Location 0C Casing type V Y <br /> Blank Screen h• <br /> Slot size �v <br /> GROUTING Bags cement <br /> Buckets bentonire—i�_ <br /> Depth to water ;Z' <br /> '6b Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y n <br /> Quantity Installed Discussed with geologist: <br /> Type of method <br /> EH 29 29 <br />