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*ft <br /> w'MONITORING WELL INSTALLATION REPbWf <br /> Date: (O 'Z O CONSTRUCTION <br /> Premise Address: 1C1t?cV&',J /07?5405&e, Total Depth <br /> Screen Length (from) (to) <br /> Well No.: IS� Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. r/YJrT9 L•0 Auger O.D. I.D. <br /> Completion -Stove pipe/christie box (circle one) <br /> Drilling Company: � <br /> Driller:�dEgi4c f Ti casing <br /> height <br /> Consultant <br /> Geologist 2 ��� - <br /> A8O&FLErJUND t,' 430 <br /> COA�LETION C <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line 5t' +'° grout <br /> Domestic well on site - (y ZD 4, _ft. <br /> If yes, location and distance - ft. <br /> TOn. _ <br /> o <br /> e <br /> C <br /> o <br /> SAMPLING slotted = x_ <br /> twc.on = <br /> Holding Temperyre <br /> Method <br /> Screening Method &V Al <br /> Tracking Sheet - y n ) <br /> SPOILS n <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Note y n / ^ _ <br /> Storage Location /! '` / Casing type Z l S� 446 C <br /> Blank ft. Screen IS ft <br /> Slot size .olio <br /> GROUTING Bags cement <br /> 7 Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios 7-CaLn -r NO 716V It/L7 Filter Pack type/size tZ- <br /> Installation Method -h R�r u Surge Block: - (y n <br /> Quantity Installed Discussed with gee ogist: <br /> Type of method <br /> EH 29 29 <br /> 6�Ti7--Ci� �C�33b3 i��e%Gf/' 1.7,U <br />