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%wc)NITORING WELL INSTALLATION REPC+y/ <br /> Date: CONSTRUCTION <br /> Premise Address-/;V�l / //U1,1.�- Total Depth <br /> Screen Length (from) (to) <br /> Well No.: (/U Filter Pack (from) (to) <br /> Bentonite (from) "• (to) <br /> Inspector: ` Grout (fr (to) <br /> 1` Drilling n D.z e <br /> Permit No. ONO*D�l Auger O. 4'---7I.D. <br /> Completion -Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing `� \ <br /> height <br /> Consultant <br /> 7/4 <br /> Geologist -- <br /> ASOV'E-GROUND C i15TY-80X <br /> COMPt.I~T(ON cOmnno <br /> SPECIAL PERMIT INFO. G=rd Swfact <br /> f <br /> Distance to sewer line G 0 S gout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - <br /> :.h a <br /> a <br /> SAMPLING slorad c <br /> saczcn — <br /> HoIding Temperature <br /> Method = 9 Pack <br /> 4. <br /> Screening Method s (06 <br /> Tracking Sheet (y/ n ) :-; <br /> ..-.�..:.:..�tt. — it. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n I q q�. <br /> Storage Location Casing ly <br /> Blank 1/1 D ft. Screen ft. <br /> Slot size !� <br /> GROUTING Bags cement r <br /> Buckets bentonit <br /> Depth to water Bags sand gravel <br /> Mix Ratios 4Q 4ttn,. Filter Pack type/size <br /> Installation Method Surge Block: - ( y u <br /> Quantity Installed g� ' . _ Discussed with geo gist: - y/ n) <br /> Type of method <br /> EH 29 29 <br />