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I <br /> . ONITORING WELL INSTALLATION REPO, . _ <br /> _ St/ nr-t �j gibov � 8 © ° <br /> Date: CONSTRUCTION <br /> Premise Address : 5 ) 7 erg rvr fm 5� r Total Depth ap SJ <br /> Well No . : 5 Screen Length (from) 2-b (to) Z3 <br /> Filter Pack (from) zS (to) Z 1 <br /> \ / Bentonite (from) Z 1 (to) $ <br /> Inspector: Y 1 C I MCI Grout (from) f 8 (to) .cum <br /> Drilling rig type <br /> Permit No._ �y7Auger O.D. n ID. /� <br /> Drilling Company:. Completion - Stove pipe hstie o (circle one_) <br /> c� SGYioer <br /> Driller:.ftli � 0 , %0 cJ � ��n 152 �k casing <br /> J height <br /> ConsultantA G f <br /> Geologist �DG1n 1 V 1 � t N V1 eVOti� <br /> ABOVE-GROUND <br /> COMPLETION T1SlY <br /> SPECIAL PERMIT INFO, Ground &urlace COMPLETfON <br /> Distance to sewer line s t grout <br /> Domestic well on site - ( y / <br /> If yes, location and distance - It. <br /> SAMPLING <br /> 0 <br /> tbttad _ <br /> taction B <br /> Holding Temperatureh <br /> Method !J _ <br /> Screening Method <br /> Tracking Sheet - ( y / n ) I ?} <br /> SPOILS <br /> Storage Method ' - &-K,yJ MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n ) <br /> Storage Location Qyt Casing type <br /> Blank � ,3 ft. Screen Z ft. <br /> Slot size of 0 7 <br /> GROUTING Bags cement Cid fb dv.�-T r <br /> e b V&k1 Buckets bentonite T o� zs �4s <br /> Depth to water------/—," 8 ' Si Bags sand/gravel I LIL <br /> Mix Ratios / 9�9 ff / G qT y//� /Yz3 Y <br /> f Filter Pack type/size A <br /> Installation Method_ ar d 0 Surge Block: - T n ) <br /> Quantity Installed_ ) Discussed with geolo 'st: - y n ) <br /> EH 29 29 <br /> Type of method Je IL <br />