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„ JNITORING WELL INSTALLATION REPC <br /> Date: i 1 CONSTRUCTION <br /> Premise Address: �1 �O C._©tfl(Y\,t S Total Depth <br /> ( Screen Length (from) (to) <br /> Well No.: `C Filter Pack (from) (to) O/ <br /> Bentonite (from) 5 [n (to) <br /> Inspector: _ A��� Grout (from) S to) K� <br /> Drilling rig type <br /> Permit No._ Z) l 0 Auger O.D. 'R ` I.D. <br /> ' 1 Completion - Stove pipe/ tstie boy (circle one) <br /> Drilling Company: y �4-'w <br /> Driller: casing <br /> height <br /> Consultant utJ <br /> 71 <br /> Geologist LA )�Q T <br /> AWVE-GACUND CNFitSTY-80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> 0/1 <br /> Domestic well on site - (y/n) ft. <br /> If yes, location and distance - r=� ft. <br /> eft. <br /> SAMPLING = s <br /> •loroi — <br /> aoc1cn <br /> Holding Temperature <br /> Method 9M W Pack <br /> Screening Method t <br /> Tracking Sheet - (y/ n) r_ _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n) 2 v Ci <br /> Storage Location Casing type c ” <br /> Blank Co b ft. Screen <br /> Slot size_ O 2 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water_ o� Bags sand/gravel <br /> Mix Ratios_ Filter Pack type/size <br /> Installation Method Surge Block: - (y/V <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />