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�%,yeIONITORING WELL INSTALLATION REPyrt' <br /> Date:�DT I t CONSTRUCTION <br /> Premise Address: <br /> n 02 Io 5 5 l 1M t7C Total Depth 7S <br /> Well No.: <br /> S P 3 S P Screen Length (from) 'JS T (to) 76 <br /> Filter Pack (from) 5 (to)— <br /> Bentonite (from) (to) 6 ' <br /> Inspector: � �f n _ �4-^_ Grout (from) (to) 4 <br /> Drilling rig type ha PI -,) <br /> Permit No. Auger O.D. 16 LD. <br /> Drilling <br /> Completion - Stove pipe/christie box (circle one) <br /> Company: W/J� <br /> Driller: V 4t't X11 casing <br /> V height <br /> Consultant /� � T <br /> Geologist �Jy''a I�vrvl� - T <br /> ABOVE-GROUND C7iRISiY-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sumacs 7— <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft' <br /> ft. <br /> tt. <br /> e <br /> c <br /> SAMPLING slottsd <br /> A\ lL wc6an �< <br /> Holding Temperature grawl pack <br /> Method = <br /> Screening Method — <br /> Tracking Sheet - ( y/ n ) 41 <br /> SPOILS D <br /> Storage Method r" A� MATERIALSIDEVELOPMENT <br /> Contamination Noted iI p p <br /> Storage Location Casing type 1 U <br /> Blank 7 D Screen S h. <br /> Slot size : h <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water SS Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: . (yff) <br /> Quantity Installed Discussed with ge ist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br /> -3 ) L4 twda� Pc�J� <br />