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•ONITORING WELL INSTALLATION REPOn7 <br /> Date: <br /> 6 D !D l' CONSTRUCTION <br /> Premise Address: rZSi S Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �G� L� Filter Pack (from) (to) toZ <br /> Q Bentonite (from) (to) <br /> Inspector: `S "z"` - Grout (from) (to) O <br /> Drilling rig e <br /> Permit No. Auger O.D. s!C " @ I.D. <br /> Completion - Stov pipe/christie box (circle one) <br /> Drilling Com an <br /> 1011-rDriller: /�Ov1aw` y casing <br /> n t.T height <br /> Consultant �t—/ �/ f�/ <br /> FT <br /> Geologist /U47 - T <br /> /ABOVE-GROUND diSA CHR*7y-Bcx <br /> COMPLETION /o"� OMPLEnON <br /> SPECIAL PERMIT INFO. O� ^ � <br /> Distance to sewer line �✓ �� grout <br /> Domestic well on site - ( y <br /> If yes, location and distance - (o2- <br /> 3 <br /> L3 _ <br /> = m <br /> y� P <br /> SAMPLING /'F' slotted <br /> E n - sec9on _ S <br /> Holding Tempera gravig pack <br /> Method = <br /> Screening Method z` <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS / IZ • _�� <br /> Storage Method 6A1 ,�"+-4 �� MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n ) v / Ale- <br /> Storage Location Casing type Get <br /> Blank ft. Screen ft• <br /> Slot size <br /> GROUTING Bags cement <br /> 1. Buckets bentonite_ <br /> Depth to water L Bags sand/gravel_ <br /> Mix Ratios Filter Pack type/size /2 <br /> Installation Method Surge Block: - (y/ nn j <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br /> GD/ 60 r- t/l/lf 2/ 00 6171 jrt <br />