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(p ONITORING WELL INSTALLATION REPO!' <br /> Date: t�lUx �hh «�3 CONSTRUCTION <br /> Premise Address: 10(0 �fYR et Total Depth -72 <br /> llAA Screen Length (from) 412 (to) ZZ <br /> Well No.: 7f+t5 Filter Pack (from) q7— - (to)� <br /> — <br /> Bentonite (from)_ I 9 (to) Imo. <br /> Inspector. Grout Mom)---L 9. 3 (to) a <br /> i - q ' Drilling rig type 15 <br /> Permit No. 13 J Auger O.D. S' I.D. <br /> :r ! Completion - Stove pip tnstie o (circle one) <br /> Drilling Company. 30 S Fl y <br /> Driller. / e� ICJRI���ii✓� I <br /> casing <br /> height <br /> Consultant 174(la ��U.elj:, j <br /> I Geologist �4(�� I' l�� ABOVE-GROUND <br /> d COMPLETION Ct1RIM43OX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. rr Graucd Surf -0 <br /> Distance to sewer line < (lb oras <br /> Domestic well on site - (y/Fff)) 3 ft. <br /> If yes, location and distance'- ft. <br /> 2Ztt — <br /> SAMPLING slonai <br /> f tadcn u: <br /> Holding Temperature q <br /> Method C <br /> Screening Method <br /> Tracking Sheet - n ) 'A x' <br /> SPOILS <br /> Storage Method� MATERIALS/DEVELOPMENT <br /> Contamination Noted - y F ) 2u J G <br /> Storage Location Casing type <br /> Blank 'Za ft. Screen Z _ ft. <br /> j Slot size • 020 <br /> 1 GROUTING Bags cement <br /> I Buckets bentonite <br /> Depth to Water Bags sand/gravel_ <br /> Mix Ratios Filter Pack type/size 241 Z <br /> Installation Method Surge Block: - ( y n <br /> Quantity Installed Discussed with geo ogisn - n) <br /> Type 'o,nff lm"Ie�t�hod N <br /> EH 29 29 V � { 50b d-, <br />