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(..�NITORING WELL INSTALLATION REPGJ <br /> Date:_ 4. 3• 12 CONSTRUCTION .. <br /> ii <br /> Premise Address: JDD E I rant Lth p w Total Depth <br /> Well No.: e)' vV "" Screen Length (from) ;Z&. S (to) <br /> Filter Pack (from) 2-e"•5 (to) . 6._5 <br /> Bentonite r• (from) 4.5 (to) 1(..S <br /> Inspector Grout (from) .o (to) Q ` <br /> Z- ?J�P 3 Drilling rig type C M b 5S HoUn�+ 5}cn1 f <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion - Stove pipe/cluistie box (circle one) <br /> _.AJ�t fel Z /"Ili/? <br /> TSom <br /> r3t �.Driller <br /> y casing <br /> n 1 height <br />' Consultant �'4C��vi �DS� -' /Tl�� y =rON Geologist �e ✓� Nlede Weskk/irCt1�— - k4t>/t �hc.L�ZG5. COWLTION bob L-1ja.rl <br /> SPECIAL PE M1T INFO. f d o - Ground Surfacy <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ ) S ft. <br /> If yes, location and distant 5 ft. <br /> 85n. <br /> !A �; O <br /> SAMPLING <br /> secicn <br /> Holding Temperature U <br /> Method cQ _ _ R'Yoa pads <br /> Screening Method &mbogh e ffl� 111CAto:L <br /> Tracking Sheet - (y/ n ) <br /> ✓ft. <br /> ' <br /> SPOILS <br /> Storage MethodG l le a i MATERIA /DEVELOPMENT „ r <br /> Contamination NIS <br /> o d • (y n K <br /> Storage LocationG!^ Casing type row <br /> w/) Blank S •5 ft. Screen �a fr. <br /> ` w' Slot size 17 , <br /> GROUTING Bags cement <br /> Buckets bentonite I`!2 qa.P, IAOi w <br /> Depth to water Bags sand/gravel 13 10450 <br /> Mix Ratios Filter Packtype(/;iaL(o <br /> Installation Method Surge Block: - �/�n ) p <br /> Quantity Installed _ Discussed with ologisr. y n ) <br /> Type of methodIr a h <br /> EH 2929 55 {J ��p - s- 1y• - <br /> 'im�� 12-b(4P32 <br /> b--U @ lo' <br />