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2 <br /> MONITORING WELL INSTALLATION REPO <br /> Date:) 1 I CONSTRUCTION <br /> Premise Address: � � � s • fi/1 Total Depth <br /> hn Screen Length (from) (to) f� <br /> Well No.: t l �O Filter Pack <br /> (from) (to) -3T, <br /> � <br /> Bentonite (from) <br /> Inspector: Grout <br /> (from) 3(a (to) a dP c�- <br /> G ( �� � Drilling rig type 0��eC� �-- <br /> Permit No. I Auger O.D. -<{ " 1 T- <br /> 6 1 Completion - Stove pipe/christie box (circle one) <br /> Consultant dL`Tn�(�� � (� <br /> Geologist S(X (JLX QNf/4 skk-up <br /> SPECIAL PERMIT INFO. <br /> ABOVE-GROUND <br /> Distance to sewer line COMPLETION CHRISTY•BOXCOMPLETION <br /> Domestic well on site • (y/ n G=nd Su*taoo <br /> If yes, location and distanc - grout <br /> n. <br /> 0 n. n. <br /> = m <br /> SAMPLING <br /> fun J <br /> Holding Temperature dottod <br /> Method &*cion <br /> Screening Method graval <br /> pack <br /> Tracking Sheet - (y/ n ) <br /> p; <br /> U n. _ <br /> SPOILS <br /> Storage Method h b f MATERIALS/DEVELOPMENT <br /> Contamination Notes - ( y/ n ) <br /> Storage Location. au e�fI" 1- AA,w�_ n 4. I, <br /> � � _ Casing type_ � V <br /> Blank y1ft. Screen 20 fr. <br /> Slot size n <br /> Bags cement 7 <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel Iq <br /> Depth to water Filter Pack type/size -14TIbigy <br /> Mix Ratios 4 bas 33 ( wain Surge Block: - ( y/ n <br /> Installation Method Discussed with geologist: - n ) <br /> Quantity Installed Type of method <br />