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MONITORING WELL INSTALLATION REPG..1 <br /> Date: r� CONSTRUCTION (y/ <br /> Premise Address: n f 1 b� Total Depth 7< <br /> ` Screen Length (from) Lj I (to) 13 <br /> e <br /> Well No.: W Filter Pack (from) 1 (to) <br /> Bentonite (from) L�(to) i33 <br /> Inspector: Grout (from) (to) <br /> Drilling rig type f,, ai� 2c sfy� <br /> Permit No. _, Auger O.D. 60 ` I.D. <br /> Completion - Stove pipe/ she (circle one) <br /> Drilling Company: <br /> Driller:— C LIL6o casing <br /> 1 height <br /> Consultant �' ti� <br /> Geologist ��Xt�l�l/)ncv-- l <br /> ABOVE-GROUND CNA75TY-80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Susan <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n /,Z 3 . ft <br /> If yes, location and distant <br /> aS ft. <br /> _ a <br /> — m <br /> SAMPLING dotted <br /> P �I n ..c5en = grsvel <br /> Holding Tem <br /> erature { D <br /> ack <br /> Method <br /> Screening Method — <br /> Tracking Sheet - (y/n ) _ <br /> �ft. EA <br /> ( ft. <br /> SPOILS <br /> Storage Method ✓ eJ MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y gnr I I r `r <br /> Storage Location Casing type Ly <br /> Blank 13 1 ft. Screen Ib fr. <br /> Slot size r y <br /> GROUTING Bags cement <br /> Buckets bentonite �Y <br /> Depth to water Bags sand/gravel <br /> Mix Ratios © Filter Pack type/size G <br /> Installation Method � Surge Block: - (y/ <br /> Quantity Installed Discussed with geol ist: - ®/ n) <br /> Type of method <br /> EH 29 29 /2-Lq- C) N_ - <br /> p�5- ►wu►-�D 2� ��qs <br />