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MONITORING WELL INSTALLATION REPO <br /> C 1 otw <br /> Date: 5 \ CONSTRUCTION Q / <br /> 1 <br /> Premise Address: vr ^ �\ ' Total Depth_ I v <br /> Screen Length (from) (to) �— <br /> Well No.: Filter Pack (from)— I H�(to) 500 <br /> n Bentonite (from) l 50 (to) r� <br /> Inspector: Grout <br /> Drilling rig N type <br /> Permit No. P '�� r I.D. <br /> Q't3t � Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:�gg� U <br /> Driller: height <br /> ��T casing <br /> T <br /> Consultant nL/V t o ✓u�l✓� ` <br /> Geologist A Agpyg.GRCUNDCHR*I Y43OX <br /> CCMPLETCN CCMPLETICN <br /> SPECIAL PERMIT INFO. G=r4 S�'n Tom" <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) -ft. <br /> If yes, location and distance - n, <br /> ft. <br /> _ m <br /> = c <br /> a <br /> SAMPLING donod <br /> saricn <br /> Holding Temperature = pavapack <br /> Method = <br /> Screening Method r' <br /> Tracking Sheet - ( y/ n ) <br /> ft. <br /> SPOILS x t <br /> Storage Method d� tl�e 1 MATERIALS/DEVELOPMENT \ <br /> Contamination Noted - (y/ n ) �� ate\ �It 5� e�) <br /> Storage Location Casing type <br /> Blank X51 ft. Screen ft. <br /> Slot size 0 I_ <br /> GROUTING <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Y 90. Filter Pack type/size I C, <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> S , ^ Type of method <br /> EH 29 29 � <br /> S <br />