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MONITORING WELL INSTALLATION REPOJci <br /> Date: CONSTRUCTION <br /> Premise Address: �3v "�� Total Depth !t.' <br /> Screen Length (from) '; (to) )4. <br /> Well No.: �'`L� Filter Pack (from) Ij; (to) Ion <br /> Bentonite (from) 11 6007, <br /> Inspector: (^ / Grout (from) (to) )� <br /> Drilling rig type <br /> Permit No. Auger O.D. Vii, I. <br /> I Completion - Stove pipe/cliristie box (circle one) <br /> Drilling Company: ('•.J <br /> Driller: casing <br /> t height <br /> Consultant '4 <br /> rITA _WVT <br /> Geologist 5 7 <br /> ABCVF--GtgMND <br /> COM?t.ETION cr�,srY-aox <br /> COMPL.EnCN <br /> SPECIAL PERMIT INFO. Ground Surface + �..�� <br /> r� <br /> Distance to sewer line o rout <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft. <br /> it. <br /> = m <br /> C <br /> SAMPLING <br /> soden <br /> Holding Temperature 4/ZA = pavoaF <br /> Method <br /> Screenin;Method r -_ <br /> Tracking Sheet - (y/ n ) v <br /> tt ;`.....ft. — fL <br /> SPOILS <br /> Storage Method I'; MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type] � r'0t SQL Sic <br /> Blank y' ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cementONu Li i IF,' > � � ✓'�..�^� T <br /> Buckets bentonite 16 <br /> Depth to water S S Bags sand/gravel_ Ito <br /> Mix Ratios /�.,'-. /L'-�t Filter Pack type/siz <br /> Installation Method Surge Block: - ( y/.10 <br /> Quantity Installed Discussed with geologist: - 3�/ 4) <br /> Type of method_•l r_ •.c.� �„-� CA.L;'4-' -?� �'� <br /> EH 29 29 <br />