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NITORING WELL INSTALLATION REPOP ' <br /> Date: /p11 CONSTRUCTION <br /> --T � / <br /> Premise Address : r6�� qq U (o N . � . ' 1r � Total Depth 75 <br /> Screen Length (from) (to) 5 <br /> Well No. : /' ( � SBZ Filter Pack (from) S (to) � 7- S <br /> Bentonite (from) 57. 5 (to) S-s <br /> InsGrout (from) 55- 5 (to) <br /> oecmr — _ <br /> Gf/ Drilling rig type bq- <br /> Permit No , / ( - 3/Z� J� <br /> Auger O .D. 100, / <br /> Completion - Stove pipe/chrisrie box (circle one) <br /> Drilling Company: �� <br /> , - / � �r casing <br /> Driller: W/1 � -� ���8e�""" - height <br /> Consultant_ D�Zx2 � <br /> Geologist ABOVEGROUND <br /> COMPL'TION CNAISTI 30X <br /> Ground SLaixa <br /> SPECIAL PERDrIIT INFO . <br /> S U proof <br /> Distance to sewer line <br /> S <br /> Domestic well on site - ( y / n ) <br /> If yes , location and distance - 59, rjft 5 7 7 5 n' <br /> x <br /> [lotted = <br /> SAMPLING aarion _ g <br /> Holding Temperature = r <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y / n ) — <br /> 7 tt. <br /> SPOILS <br /> Storage Method Dom. ulr MATERIALS/DEVELOPMENT t ' <br /> Contamination Noted r! r � C /0 i/W <br /> k <br /> Srorage Location OCasing type 7 <br /> Blank ff- fr. Screen ! S ft <br /> Slot size 0 2_ _ <br /> GROUTING Bags cement <br /> r Buckets bentoniteQCa ��• <br /> Deorh to water 65 Bags sand/gravel s� <br /> Mix Ratios POW—,Ay 1�� Filter Pack type/size <br /> Installation Method Dzf^ko uwC Surge Block: - ay n ) <br /> Quantity Installed Discussed with geolQ ist: n ) <br /> Type of method 3 L S _� <br /> lZ ( I I ILII � W � / rJZ <br />