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10NITORING WELL INSTALLATION REPOn. <br /> Date: ( Z D CONSTRUCTION <br /> Premise Address: 8I ZS S� CSC Total Depth <br /> t Screen Length (from) (to 2-2- <br /> Well No.: Filter Pack (from) 3 (to) 20 <br /> Bentonite (from) 20 (to) IV <br /> Inspector: _ Grout (from) (to) <br /> s/2 ©Q �65� Drilling rig type <br /> Permit No. << Auger O.D. I.D. <br /> - n <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> (y'�-P �J�Gt.C�(' y.� _ <br /> Driller: 7,iL20YTZ f LC�t- f C� casing <br /> height <br /> Consultant <br /> Geologist ©d <br /> MY <br /> ABOVE-GROUND <br /> OOAFL.ETION C ISTY-BO <br /> SPECIAL PERMIT INFO. Ground Sudan <br /> Distance to sewer line /yd'-C OroaII <br /> Domestic well on site - ( y<D ft <br /> If yes, location and distance - <br /> ft. <br /> a <br /> a <br /> _ a <br /> C <br /> SAMPLING slotted = S' <br /> section — $ <br /> Holding Temperature <br /> Method — gmyel Pack <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) Y <br /> SPOILS T p <br /> Storage Method SS f� L- MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) n e <br /> Storage Location Casing type 170% S <br /> L 46 I' <br /> Blank 2Z ft. Screen 15 ft. <br /> Slot size 10 <br /> GROUTING Bags cement 4r a" <br /> Buckets bentonite t <br /> Depth to water Bags sand/gravel Y41, Q <br /> Mix Ratios f' Filter Pack type/size 2 2-- <br /> Installation <br /> ZInstallation Method Surge Block: - (y n <br /> Quantity Installed YL L Discussed with geologist: - (y n ) <br /> Type of method <br /> EH 29 29 <br />