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`"'StRONITORING WELL INSTALLATION REPIMT <br /> Date: (D JG4n CONSTRUCTION <br /> Premise Address: IJ Z U �kvt 1!�� E ✓g�{ Total Depth <br /> Screen Length (from) _3 S" (to) SS' <br /> Well No.: Wu) S A Filter Pack (from) SS` (to) 33 <br /> Bentonite (from) 33 ' (to) 3/ <br /> Inspector: 16("�v3c'n Grout (from) (Eo) <br /> Drilling rig type <br /> Permit No. DD 3 z3 Z U Auger O.D. I.D. <br /> Drilling Company: V <br /> q U ' Completion - Stove pipe/christie box (circle one) <br /> )7 �� �r� �('�`, , -�`��- <br /> Driller: .� V i21U i 1 y casing <br /> height <br /> Consultant 611V t �2d�A��s' S <br /> Geologist e4 ✓\. GceA oe!� <br /> $,kbw guLtOlt OK) ABOVE-GROUND CHRX7Y4= <br /> COWLEiION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surlxw <br /> Distance to sewer line gr <br /> out <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - tt <br /> — a <br /> q <br /> _ O <br /> C <br /> O <br /> SAMPLING Blood _ S <br /> tac5on <br /> Holding Temperature <br /> Method =_ <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type �YC <br /> Blank '5t-10' 'S fr. Screen ZD (2e <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gavel <br /> Mix Ratios Filter Pack type/size 1-i" (y;k, 'r 3 <br /> Installation Method Surge Block: - (0 n_) <br /> Quantity Installed Discussed with geologist: - (P n) <br /> Type of method <br /> EH 29 29 <br /> �Lr.t (vl�aY LG� <br />