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r,,.,,JNITORING WELL INSTALLATION REPGW, <br /> Date: D T CONSTRUCTION <br /> Premise Address: Total Depth <br /> [, Screen Length (from) I B (to) <br /> Well No.: rn Yy-�uk� Yy\ Filter Pack (from) 119 (to) 5, <br /> Bentonite (from) 5 (to) <br /> Inspector: Grout (fr m) L4 -(to) -e- <br /> Drilling rig type L,� D ff-13 <br /> Permit No. d d Auger O.D. I.D. <br /> na Completio • Spve pipe luistie box (circle one) <br /> Drilling Company: � n�A I+,E'� <br /> Driller: casing <br /> height <br /> Consultant �'�-c�� <br /> GeologistC; - _ <br /> A80VE-GACVND C}VUM-8OX <br /> COMPLETION COMPLEMN <br /> SPECIAL PERMIT INFO. Ground Suxfacs <br /> Distance to sewer line <br /> Domestic well on site - y n) ft. <br /> If yes, location and distance - <br /> SAMPLING slot-ad _ <br /> aocicn :. <br /> Holding Temperature <br /> Method r <br /> Y) �: <br /> _ sPack. _ <br /> Screening Method f ' <br /> Tracking Sheet - ( y/ n) �`� _ <br /> a.l.�..._ft. <br /> SPOILS <br /> Storage Method 5 MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y I r \/ <br /> Storage Location Casing type `� <br /> Blank `l�— ft. Screen r 0ft. <br /> Slot size o f <br /> GROUTING Bags cement U ba-�2 — 3 t Pio <br /> Buckets bentonite I - u <br /> Depth to water j Bags sand/gravel <br /> Mix Ratios Filter Pack type/size C !Y <br /> Installation Method ILLi Surge Block: - (y/ <br /> Quantity Installed l) Discussed with geo ogist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />