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MONITORING WELL INSTULATION RErURT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) 5 (to) <br /> Its <br /> Well No.:��iV Z Filter Pack (from)fo (to) <br /> l'J, � n � <br /> Bentonite' (from) 43 (t 6) <br /> Inspector: '+ -� Grout Mop) '36 (to) <br /> Drilling rig type A <br /> Permit No. Auger O.D. I[t( - I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:CI.S � <br /> Driller- casing <br /> height <br /> Consultant 4&e <br /> Geologist C l ^ <br /> ABOVE-GROUND <br /> COWLETCN ctt�:srr-w <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line 9f0� <br /> Domestic well on site - {y/ n ) <br /> If yes, location and distance - ft' <br /> C <br /> SAMPLING ebb u -- <br /> N�pk` <br /> Holding Temperature v". <br /> VzW pack <br /> Method <br /> Screening Method = <br /> Tracking Sheet - Cy/ n ) ;: <br /> SPOILS rz� <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type + $U <br /> Blank of ft. ScreenhA.! 2-0 ft. <br /> Slot size O o30 <br /> GROUTING Bags cement ZO y7 <br /> Buckets bentonite 2 <br /> Depth to water Bags sand/gravel iAaAz .+ <br /> Mixt Ratios Filter Pack type/ 'ze <br /> Installation Method Surge Block: - n) <br /> Quantity Installed Discussed with geo st: - n ) <br /> Type of method n <br /> EH 29 29 <br />