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ONITORING WELL INSTALLATION REPO <br /> Date: / CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) �fi'7` (to) <br /> Well No.: Filter Pack (from) 4T (to) Zcj <br /> / Bentonite (from) 2-11' (to) Z ey <br /> Inspector: it Grout (from) Zt�; (to)_ <br /> Drilling rig typeC! <br /> Permit No.--- j —f�G L�� Auger O.D. e%r I.D. '/ <br /> Completion - Stove pi c uisri�c circle one) <br /> Drilling Company: � G!o <br /> OO <br /> Driller: 12 /s;/Cnc( L' Tcasing <br /> height <br /> Consultant Xlr-e" / <br /> nil T'4' <br /> Geologist �?' - T <br /> ABOVE-GRCUND �� <br /> COMPLETION <br /> SPECIAL PERMIT INFO. G=r,d Surface <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n ) �_ _ft. <br /> If yes, location and distance - ft. <br /> 3Z ft. <br /> SAMPLING <br /> a <br /> elot•.a.•1 �^ c <br /> s#don <br /> Holding Tem eratge �� v <br /> Method <br /> gmy pads <br /> '.1-� �/������nG`1 ..;. <br /> Screening Method <br /> Tracking Sheet - C/ n ) _ <br /> y/�'�~''J� _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted - / <br /> Storage Location c.�7 J�`C Casing type -Z I /`n��-- <br /> Blank_____,? Z— ft. Screen ft. <br /> Slot size 7U. <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios lyel Filter Pack type/size -Oi� 3 <br /> Installation Method_ Frzx_ Fid!% Surge Block: - 0n ) <br /> Quantity Installed Discussed with geologist: - % n ) <br /> Type of method <br /> EH 29 29 <br />