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)NITORING WELL INSTALLATION REPC <br /> �J <br /> Date: � / r� CONSTRUCTION <br /> Premise Address:--- 12"'1. s C�-'-� Total Depth <br /> Z Screen Length (from) (to)� <br /> Well No.: Filter Pack (from) SS (to) 3l•$ <br /> Bentonite (from) (.R' (to) Z9- 2— <br /> Inspector: �/, Grout (from) Z°(-2 (to) 0 <br /> / <br /> r23 5- Drilling rig type <br /> Permit No. �/ � Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:_ <br /> .�'6-CSC casing <br /> Driller: <br /> height <br /> Consultant T <br /> T <br /> Geologist AE&rz-GRMNO <br /> X <br /> COWPL.-KION (iiN <br /> Ground Surface �— <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ ft. <br /> 3! n. <br /> If yes, location and distance - <br /> 35 tc. <br /> _ <br /> CD <br /> _ o <br /> :lotted <br /> SAMPLING <br /> U C = QravW Pads <br /> Holding Temperature <br /> Method <br /> Screening Method \)nA _ <br /> Tracking Sheet - y n ) Jr� s <br /> ft. <br /> SPOILS <br /> Storage Method — MATERIALS/DEVELOPMENT <br /> Contamination Noted -On ) i► it <br /> Storage Location Casing type <br /> Blank V5 ft. Screen 1O ft. <br /> Slot size f4"® .b 10 <br /> GROUTING Bags cement <br /> Buckets bentonite 1 2 ` `( <br /> V7 Depth to water V Bags sand/gravel tO <br /> Mix Ratios Filter Pack type/size ]L- <br /> Installation Method Surge Block: - (9/ n ) <br /> Quantity Installed Discussed with geologist: - & n ) <br /> Type of method i(:, <br /> /vO <br /> mai 2 � <br />