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_ONITORING WELL INSTALLATION REPO <br /> Date: //s /�OA0/6 CONSTRUCTION <br /> Premise Address: w 6 Yi sy .ra Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �-Jr Filter Pack (from) / —(to) <br /> � <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (o (to) 0 <br /> D��/Z/ Drilling rig type 14 Z - <br /> Permit No. Auger O.D. I.D. 9 <br /> / Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: !9'L4L'-� <br /> UU <br /> Driller: IAZ7 7" / I casing <br /> __ -- JJ � . <br /> Consultant�LC� height <br /> 7,1 <br /> Geologist •- T <br /> ABOVE-GROUND <br /> COMPLETION CNRSST'Y-80X <br /> COMPLEMCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line U��� grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft' <br /> ft. <br /> = o <br /> _ c <br /> SAMPLING tlottad — r. <br /> sacdon <br /> Holding Temperature <br /> Method = P <br /> ack <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method 515 q, 4 MATERIALS/DEVELOPMENT <br /> Contamination Noted - n ) �I, <br /> Storage Location 0J i � Casing type OZ�r� `6 /✓C <br /> Blank ft. Screen /'D ft. <br /> Slot size 04 If <br /> GROUTING q^ags cement "3 -Ga-� <br /> Buckets bentonite 4t&4 <br /> Depth to water / Bags sand/gravel z 3•L 50'f .,..� <br /> Mix Ratios q7 // t 2 1424 Filter Pack type/size <br /> Installation Method Surge Block: - (yP09iS-t-!:-"-( <br /> Quantity Installed = Discussed with gey <br /> Type of method <br /> EH 29 29 <br /> �G �o <br />