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iVITORING WELL INSTALLATION REP(O <br /> Date:_ b�tib /��� CONSTRUCTION <br /> 11 <br /> Premise Address� �j N� aoper Jr . 9-e'(_01M Total Depth <br /> Screen Length (from) '23 (to) 33' <br /> Well No.: My 3S Filter Pack (from) 21 (to) qQ1 � <br /> t-_ Bentonite (from) 1$' (to) 2 <br /> Inspector: _ Gu�f�C 6 on7AI GZ Grout (from) 2%1.0wfAV-0 (to) 24 ' <br /> Drilling rig type 01-C9 <br /> Permit No. Auger O.D. $ I.D. �y•t�" <br /> Drilling Company: <br /> w1OAV PVA Completion - tove pip christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist .. <br /> ABOVE-GRCUND <br /> COWLETCN CHRtM-80X <br /> COMPLEMN <br /> SPECIAL PERMIT INFO. Ground Stxfacs ��....� <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - <br /> 23 ft _ <br /> SAMPLING \951 SU1, slon4d ;- a <br /> Holding Temperature 4°6 <br /> Method nWA ta:�&;•.''C <br /> Screening Method 44 r _ <br /> Tracking Sheet - ( y/ n ) <br /> 33 ft. -3 U ita <br /> SPOILS <br /> Storage Method Ss cl6ll i fur MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location wsA Casing type S(keolJ l{ jigfVC. <br /> Blank-23fi 3' Screen t-d ft. <br /> Slot size -0�- MtAu <br /> GROUTING Bags cemen�jry�J6 4"s Ahvz 4 h�✓ 3 <br /> Buckets bentonite 136A <br /> 1OP'DepLh to water �/` Bags sand/gravel C 4" rd U,_ bud )IldAkvw <br /> Mix Ratios __ Filter Pack type/size '^ it <br /> Installation Method— 1t'P✓mP I irBr.:e Surge Block: - (y/ n ) <br /> Quantity Installed _ Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 - <br />