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)NITORING WELL REPOP <br /> Date: 92e�pZb 61 CONSTRUCTfON <br /> Premise Address:3sd ��1� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �y� , /t�leb POJ 7 A41,4 Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit Pp Auger O.D. I.D. <br /> 6XSV I/ q Completion - Stove pipe/clu-istie box (circle one) <br /> Dcil4ing Company. omit/ <br /> Driller: casing <br /> ` �7— height <br /> Consultant <br /> Geologist <br /> ABOVE-GRCUND <br /> CC&FLFrCN CHR1STY-BOX <br /> SPECIAL PERMIT INFO. COM =TICN <br /> Ground Sufacs <br /> Distance to sewer line u"`� grout <br /> Domestic well on site - y/ n ) 1 <br /> If yep, location and dista ce - T ft. <br /> ft. <br /> = m <br /> — o <br /> SAMPLING — o <br /> tloC.ad — c <br /> 'I6 aoct.cn . <br /> T <br /> Holding Temperature c, — <br /> Method = Brava pack <br /> Screening Method <br /> Tracking Sheet -�/ n ) <br /> —ft. <br /> SPOILS <br /> Storage Method MATE RIALS/DEVEI.OPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type 41 ipVC <br /> Blank ft. Screen h. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Rat'os __ Filter Pack type/size <br /> Install tion Method Surge Block: - ( y/ n ) <br /> Qua iry Installed Discussed with geologist: ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />