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i <br /> .ONITORING WELL INSTALLATION REPO <br /> I <br /> Date: �3 Lq r CONSTRUCTION <br /> Premise Address: S ( V 6.�k CJ t / t Ad Total Depth go <br /> Screen Length (from) VV ' (to) C " <br /> Well No.: 4 Filter Pack (from) 7�? ' (to) 3Vz- <br /> Bentonite (from) 3Ui (to) & ' <br /> Inspector: tK tY Y Grout (fro`Z) s _(to) <br /> Drilling rig type 4 U <br /> Permit No. 00 Auger O.D. R I,D. 31y <br /> Completion - Stove pipe/cltristie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height,% <br /> Consultant �l Geologist �- 4�m \ <br /> ABOVEmGROUND CHAISTY BCX <br /> COMPLEfAN CCMPLEnCN <br /> SPECIAL PERMIT INFO. ground Saha <br /> Distance to sewer line ('t'jt-- grout <br /> Domestic well on site - ( y tn) <br /> If yes, location and distance - tie <br /> fta Seem 4 <br /> = c <br /> SAMPLING .larad <br /> (i L a 'cn <br /> Holding Temperature t "'•, - gavoIPacu <br /> Method l 4 L✓h w 5T�pcm� -;•: _ <br /> Screening Method Pt_ <br /> Tracking Sheet - �(y)/ n mop, <br /> . <br /> 4t. = LL <br /> SPOILS <br /> Storage Method (� S � �C MATERIALS/DEVELOPMENT <br /> Contamination Noted - y y n ) , , LXU / <br /> Storage Location Casing type ?— <br /> Blank '� ft. Screen / ft. <br /> Slot size QO2-& <br /> GROUTING Bags cement I <br /> Buckets bentonite %z a- Q.E <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n : _ <br /> Quantity Installed 2- Gu t Discussed with geologist: ( yn ) <br /> Type of method <br /> EH 29 29 <br />