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MONITORING WELL INSTALLATION REPC� r CO <br /> . 335 <br /> 2 q 355_7/ <br /> Date: 3 No �� `� CONSTRUCTIO �+t LZe 502 T <br /> Premise Address: 2rJ�S fH�r�fi I C(�.b Total Depth �5 <br /> Screen Length (from (to) <br /> Well No.: MW IZ Filter Pack (from) (to) <br /> 2 Bentonite (from) (to) <br /> Inspector: �CGt.�^�-� / Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: <br /> C�ve�l� ��l�t ns Completion - Stove pipe/christie box (circle one) <br /> Driller: Cy-i S SA- casing <br /> height <br /> Consultant ' ` 1' I Cr^1 6^1 ITTLT <br /> "', M— —QW—f <br /> Geologist �u Q N� L`/` - <br /> ABOVE-GROUND OHAISiY BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground SuAxs <br /> Cj� loo <br /> Distance to sewer line to _ r.{ Grout <br /> Domestic well on site - (y/ n ) 15- L <br /> If yes, location and distance - 20-2.Li ft. <br /> 25' 1.Li ft. <br /> 35— No eco = <br /> -"twe 'Etoa�v�S Sfiv�OJ�.S � 't5 - hl,.egr<y ua•a-D�n, = c <br /> SAMPLING �U O slatted _ c <br /> �5 O �n secion — <br /> Holding Temperature - gravel pack <br /> Method — <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type tJA- <br /> Blank NA' 8. Screen LA ft. <br /> Slot size <br /> GROUTING Bags cement 1 <br /> Buckets bentonite _ <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Ta Ir: Surge Block: - ( y/ n ) <br /> Quantity Installed Iri S Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 �.(N; ,. ,( Q„ n !� R�Q ►W�Y. . <br /> l�vM,r�l`utN,Kv <br /> W) V\ow)ws -r- "A <br />