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N _ <br /> ONITORING WELL INSTALLATION REPO. <br /> Date: % /1 z/Za / L CONSTRUCTION <br /> Premise Address: j 1 �7 j /rNLa ,fwTotal Depth 5 <br /> ' <br /> � <br /> Wel] No. : _ }� Screen Length (from) Z34, (to) 2S <br /> Filter Pack (from) 2 l (to) z 5 <br /> inspector: � 3 Bentonite (from) 8 (to) z / <br /> /ggi � � . /,Grout (from) / (to) / N <br /> Drilling rig type G✓YI E 75 <br /> Permit No . 4!5 p Auger O.D. it I.D. <br /> Drilling Company: Completion - Stove pipe/christie box (circle one) <br /> // !/�/qw� !�ybp,Ly,(,�,.t,�,,,y�' <br /> Driller:_ ele Sy' c� Z<� at, casin <br /> 4 <br /> ( height <br /> Consultant /1 lepL� M7:FGeologist tin J!' ( 9h H%/y� ABOVE-GROUNDCOWLETION <br /> SPECIAL PERMIT INFO. , / G�� g�� <br /> Distance to sewer line / I/ a �` grout <br /> Domestic well on site - <br /> If yes, locieri-aad distance - 19 no <br /> a ft. <br /> 23 tt <br /> SAMPLING � <br /> — <br /> tac5on — <br /> Holdin emperature = <br /> Me d — I�w P� <br /> S ening Method <br /> Tracking Sheet - ( y / n ) — <br /> .?S tt. <br /> SPOILS <br /> Storage Method -,yh v✓t S MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y /a p <br /> Storage Location o Casing type a' pvC <br /> Blank /J - 2 'S ft. Screen L -S ft. <br /> Slot size e�90 e;) / y /"4 <br /> GROUTING Bags cement <br /> Buckets bentonite lWJ <br /> Depth to water P Bags sand/gravel 5 = 75 It F .. j <br /> Mix Ratios o � ff4jpe a .4 c Filter Pack type/size <br /> Installation Metlidd _e Surge Block: - / n ) <br /> Quantity Installed g/j J Discussed with ologIs t <br /> EH 29 29 Type of method &42 �or2 <br />