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MONITORING WELL INSTALLATION REP-e-T <br /> CONSTRUCTION <br /> Total Depth <br /> Premise Address: I Y 1 <br /> I n r Screen Length (from) <br /> M d v V g Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> Grout (from) (to) <br /> inspector. Ding rig type <br /> Auger O.D. I.D. <br /> Permit No- Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> 7 casing <br /> Driller. Iff <br /> height <br /> Consultant <br /> Geologist /ISOYE-GRCUNO CFALS—n-BOX <br /> t✓?�..ET10N COMPL=—CN <br /> Grvctnd Sutaes <br /> SPECIAL PERNIIT INFO. S r <br /> grout <br /> Distance to sewer line `t- <br /> Domestic well on site - C y/ n ) S 'D 1.,-30) <br /> If yes, location and distance - ' -�- <br /> cap <br /> SAMPLING wc:cn71VOI pack <br /> — <br /> Holding Temperature <br /> Method <br /> Screening Method S �� <br /> Tracking Sheet - C y/ n ) <br /> AJ 14 a lL <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method W <br /> Contamination Noted - y/ n) asing type <br /> Storage Location s(✓n �a Z� Blank ft Screen ft. <br /> Slot size <br /> Bags cement <br /> GROUTING X3.5 Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water V Filter Pack typesize <br /> Mix Ratios Surge Block: - C y/ n ) <br /> Installation Method Discussed with geologist- - C y/ n) <br /> Quantity Installed foj�,\,Aj Y Type of method <br /> EH 29 29 <br /> X 1 1 J � , I SrC CSJ l <br /> 15' <br />