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i <br /> MONITORING WELL INSTALLATION REPCmf <br /> Date: ` ' ` /F CONSTRUCTION Gn,/ <br /> Premise Address : ung ` Total Depth M i 5D <br /> vu A41lZa Screen Length (from) (to) <br /> Well No. : Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. �� aS6D 3 S Auger O.D. I.D. <br /> /] Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: ��l.P/ <br /> Driller: t casing <br /> height <br /> Consultant <br /> Geologist - <br /> ABOVE-GROUND ��( I CHMMS BOX <br /> COMPLETION COMPLETI <br /> SPECIAL PERMIT INFO. nd S"rf <br /> grout <br /> Distance to sewer line A—) 35 <br /> Domestic well on site - ( y n , CO Affk/ <br /> If yes, location and distance - qb ft. <br /> a <br /> = c <br /> o <br /> SAMPLING slotted <br /> soclon — $ <br /> Holding Temperature - gnvel Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y / n ) <br /> SPOILS �.`�`"�C ', <br /> Storage Method MATERIALS/DEVELOPME T <br /> Contamination Noted - ( y n k T V <br /> Storage Location Casing type Sb1 <br /> Blank fr. Screen /6 ft. <br /> Slot size nib <br /> GROUTING Bags cement <br /> Buckets bentonite_ 74 26 <br /> Depth to water 7" lV Bags sand/gravel <br /> Mix Ratios Filter Pack type/size t2 <br /> Installation Method Surge Block: - ( y n <br /> Quantity Installed Discussed with geologist: - ( yo <br /> Type of method <br /> EH 29 29 <br />