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/ONITORING WELL INSTALLATION REPC• <br /> Date: f�� �C� ( CONSTRUCTION <br /> Premise Address: Z�l`) N'44 7a-r F Total Depth Q-5 <br /> Screen Length (from) --S (to) S <br /> Well No.: Filter Pack (from) 15 (to) <br /> 9 Bentonite (from) 3 (to) <br /> K/ <br /> Inspector: 1- w t't•� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: ' c' <br /> Driller: casing <br /> height <br /> Consultant T <br /> Geologist �w - T <br /> ABOVE-GROUND CHRISTY-BOX <br /> COMPLF7K)N COMPLEnON <br /> SPECIAL PERMIT INFO. Ground Surfan <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> ft. <br /> If yes, location and distance - <br /> ft. <br /> ft. <br /> _ _ a <br /> = m <br /> — e <br /> SAMPLING V ' dotted <br /> /(/ &*don 'F _ <br /> Holding Temperature A) /-A = gmvel D <br /> ack <br /> Method <br /> Screening Method —_ <br /> Tracking Sheet - ( y/ n ) _ <br /> tt. <br /> SPOILS <br /> Storage Method � iodA � MATERIALS/DEVELOPMENT <br /> Contamination Note (y/ n')` , <br /> Storage Location's..o l m�T Uzi u it Casing type FOU <br /> Blank 5- ft. Screen U ft. <br /> Slot siz <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel l <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (yn <br /> Quantity Installed Discussed with ge 091st: - (}�/ n ) <br /> Type of method <br /> EH 29 29 <br />