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MONITORING WELL INSTALLATION RE* <br /> Date: k�,�+�f(� r CONSTRUCTION �LL <br /> Premise Address: 3d�3 .... V]AIAa� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �S� J'L� Filter Pack (from) (to) o <br /> Bentonite (from)_f o (to) D <br /> Inspector: td r Grout (fro ) It)!j uN <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> taf Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: Q-S <br /> Driller: casing <br /> height <br /> Consultant <br /> T <br /> Geologist •- V T <br /> DOWPL <br /> AND CHR*TY-BOX <br /> COMPLETTIOION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Solan <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) o tt <br /> If yes, location and distance - p <br /> ft. <br /> r <br /> o <br /> SAMPLING slotted <br /> secdon =_ <br /> Holding Temperature = gmvW pack <br /> Method ' <br /> Screening Method x> <br /> Tracking Sheet - (y/n ) ���Fr,, <br /> ._l_Ltt. <br /> SPOILS (2 0 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) !� Edi✓ <br /> Storage Location Casing type <br /> Blank GIS fr. Screen ft. <br /> Slot size /)-020 <br /> GROUTING Bags cement <br /> ! Buckets bentonite <br /> Depth to water (0 13I5 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size rw-� <br /> Installation Method Surge Block: - (y 41 � <br /> Quantity Installed Discussed with geologist: -U1y n) <br /> Type of method <br /> EH 29 29 <br />