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MONITORING WELL INSTALLATION REPOP*"f <br /> Date: �/ SCJ / '/ ! CONSTRUCTION <br /> Premise Address: N 1611 404 / Total Depth <br /> ,','/ L Screen Length (from) (to) <br /> Well No.: / L7 i Z' Filter�/J Filter Pack (from) (to) <br /> n / 61A_ Bentonite (from) (to) <br /> Inspector: �/k�� t�p$� Grout (from) 5 (to) <br /> Drilling rig type21 Zr_ <br /> Permit No. Sli ds6 Auger O.D. I.D. z <br /> C. Completion -Stove pipe/christie box (circle one) <br /> Drilling CompanyG' <br /> Driller: <br /> I� 7� casing <br /> height <br /> Consultant <br /> //tn! CWIC �"� ..a, <br /> Geologist XABOVE-GROUND <br /> OOWLETION CHAlPLEnOX <br /> PLETION <br /> SPECIAL PERMIT INFO. Ground SurtWe <br /> Distance to sewer line G grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> a <br /> P <br /> . C <br /> O <br /> SAMPLING slottr<d = c <br /> wcdon <br /> Holding Temperature -- Nom` q�YW paq <br /> Method <br /> " <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method %`�F //IY/N MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y Cy2 .. �1. �� <br /> Storage Location Casing type 7� <br /> Blank Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios • 7F f7mr / /� Filter Pack type/size /2 <br /> Installation Method Bt.i Surge Block: - (y/ n <br /> Quantity Installed_ /zf Discussed with geologist: - (y/C)) <br /> Type of method <br /> EH 29 29 <br /> \ .J4, S <br />