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OFONITORING WELL INSTALLATION REPO <br /> 75r <br /> Date: /U 2L P l Z� l�! $ CONSTRUCTION <br /> Premise Address: Total Depth 76 <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) QO (to) <br /> Bentonite (from)�(to) - <br /> Inspector: Grout (fro m`�(to) o <br /> 5 / Drilling rig typ�� <br /> Permit No. fo Auger O.D. /f! i <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling CompanyA:/ <br /> Driller: Nam casing <br /> height <br /> Consultant <br /> Geologist CA� <br /> ABOVE-GROUND CNSiY <br /> Ai -BOX <br /> COMPLETbN 6 OMPLE71ON <br /> SPECIAL PERMIT INFO. rd Sort <br /> YO� proof <br /> Distance to sewer liney�¢ <br /> Domestic well on site - ( y/ n ) 72- <br /> ft. <br /> If yes, location and distance - 75 ft. <br /> ft. <br /> _ a <br /> _ m <br /> C <br /> SAMPLING sloes <br /> socton <br /> Holding Temperature = pa`s Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS d <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) �f` <br /> Storage Location Casing type <br /> S / ft. <br /> Blank_ fr. Screen <br /> Slot size of V <br /> GROUTING Bags cement - <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios - /LLGO�M� ��s Filter Pack type/size Z <br /> Installation—-Method �— Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br /> /o/y2-s — n�is�0� <br />