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%%wiONITORING WELL INSTALLATION REPOPW <br /> Date: CONSTRUCTION <br /> Premise Address: l 5 W Total Depth -'V3 <br /> p� Screen Length (from) (to) C S <br /> Well No.: ( \ Filter Pack (from) -'k (to)�— <br /> �`�0'-► lY v Bentonite (from) ( (to) S <br /> Inspector: Grout (from) (to) b <br /> Drilling rig type <br /> Permit No. Auger O.D. (y'' I.D. <br /> Drilling Company: Completion - Stove pipe/ch istie box (circle one) <br /> �O vt �'r^-'l� <br /> Driller: <CUv`~( Gvc� casing <br /> \ _ _ti height <br /> Consultant Vw�c`Y <br /> Geologist i^ <br /> ABOVE-GROUND <br /> COMPLETION CNRi.STY-80X <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/n) >t. <br /> If yes, location and distance - <br /> m <br /> SAMPLING slotted a. <br /> section <br /> Holding Temperature <br /> Method <br /> E <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) �� J <br /> Storage Location Casing type_j <br /> Blank ft. Screen ft. <br /> Slot size t9-'L--" <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water +f Bags sand/gravel <br /> Mix Ratios -to [bac 1.�--1 ;2_ Filter Pack type/size <br /> Installation Method n v,,,vo Surge Block: - (y/n) <br /> Quantity Installed —�� Discussed with geologist: - (y/n) <br /> Type of method <br /> EH 29 29 <br />