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MONITORING WELL INSTALLATION REPOWL' <br /> Date: 7/ I - I CONSTRUCTION <br /> Premise Address : Z ' STK Total Depth <br /> Screen Length (from) (to) I <br /> 6t { W / L Filtei Pack <br /> Well No.: <br /> (from) (to) t7 <br /> Bentonite (from) 1 :t (to) <br /> l <br /> Inspector. Grout (from) ll (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> p Completion - Stove pipe/clu-istie box (circle one) <br />'i Drilling Company: AM l K '^-x-C�(' <br /> Driller: casing <br /> height <br /> Consultant ` <br /> Geologist /rf <br /> ABOV&GACUND GIWHISIY 30X <br /> COWLEiION comPLE71CN <br /> SPECIAL PERMIT INFO. Grwrd S xt + " <br /> J <br /> Distance to server line P^ 15 grout <br /> Domestic well on site - ( y / n ) I I - g, <br /> If yes, location and distance - g- <br /> R. <br /> C <br /> O <br /> SAMPLING slorai <br /> toc*cn — <br /> Holding Temperature = ynvst pack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y / n ) <br /> = n. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted • ( y / n ) l� <br /> Storage Location Casing type d NLI <br /> Blank I C fro Screen. h• <br /> Slot size 04 OZ <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water ZZ Bags sand/gravel <br /> Mix Ratios AA Filter Pack type/ ize 2 I 'L <br /> Installation Method Surge Block: - Uy / n ) <br /> Quantity Installed Discussed with geologist: / n ) <br /> Type of method <br /> EH 29 29 <br />