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tv 551ITORING WELL INSTALLATION REPOn Poe <br /> Date: X CONSTRUCTION <br /> Premise Address: 311X6 X6 f Total Depth l(� <br /> L 9-6 <br /> Screen Length (from) (to) <br /> Well No.: ��� Filter Pack (from) / (to) O <br /> Bentonite (from) <br /> Inspector: Grout (from) 3S S (to) <br /> 7Drilling rig type /v <br /> Permit No. 0 353 Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: <br /> `� / casing <br /> height <br /> Consultant Ab:4� T <br /> Geologist <br /> COMPLETION COMP ON <br /> SPECIAL PERMIT INFO. Ground Surfac9 <br /> Distance to sewer line 10-121 grout <br /> 1 <br /> Domestic well on site - (y<D ft. <br /> If yes, location and distance - O ft. <br /> ft. <br /> 83 <br /> — <br /> = m <br /> a <br /> SAMPLING fl slotted <br /> !�(T� u-p• aac5on <br /> Holding Temperature f = gavel pack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (I;Pn) Nr <br /> / <br /> SPOILS pp � - - q <br /> Storage Method �-4 l�c�-� y T' MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) ZI• [�1�11 �'O <br /> Storage Location Casing type T l� <br /> Blank J4'S ft. Screen_S R• <br /> Slot size <br /> GROUTING Bags cement <br /> rr ( Buckets bentonite �- <br /> Depth to water b� Bags sand/gravel <br /> Mix Ratios 7 Filter Pack type/size <br /> Installation Metho Surge Block: - (y <br /> Quantity Installed Discussed with geologist: - (y nn <br /> Type of method <br /> EH 29 29 <br /> �,VV is <br />