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"�%ITORING WELL INSTALIATION REPOR. <br /> 5 <br /> Date: I�� ���I CONSTRUCTION I <br /> Premise Address: ��� - 7` t� Total Depth 7�" <br /> `I Screen Length (from) Z (to) 165- <br /> Well No.: V `' �'r 3 A-�� �L t Filter Pack (from) 7-&.<_ (to) I? <br /> - Bentonite (from) /3 _(to) <br /> Inspector: '`�'� Grout (from) f (to) cc�w <br /> Drilling rig type Sflc.-- <br /> Permit No. ` l 7 y Auger O.D. 11" _ I.D. <br /> t� Completion - Stove pipe/ tie x (circle one) <br /> Drilling Company: l��S/''`'�'`J /��...e-�Z'�-�� <br /> casing <br /> Driller: height <br /> Consultant S <br /> Geologist R[ ABOVE-GROUND <br /> COMPLETION Ci1AISTY-BOX <br /> COMPLETION <br /> _ Ground Surface <br /> SPECIAL PERMIT INFO. <br /> >S�, grout <br /> Distance to sewer line <br /> Domestic well on site - (y ) ft• <br /> If yes, location and distan l ft• <br /> ft. <br /> Q <br /> SAMPLING slotted +' — <br /> sxdon <br /> o gravel pack <br /> Holding Temperature L-- <br /> Method ✓l <br /> Screening Method <br /> Tracking Sheet -�/ n ) zS <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n ) <br /> Storage Location fin- Casing e 7 u��� <br /> Blank ft. Screen <br /> Slot size .U 2�0 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel� <br /> Mix Ratios a�;( c Filter Pack type/size <br /> Installation Method .c.c- Surge Block: - [ n <br /> Quantity Installed Discussed with geo ogist: <br /> y <br /> Type of method <br />