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OONITORING WELL INSTALLATION REPO <br /> Date: ✓ /" / 9 7 CONSTRUCTION <br /> Premise Address: d ie'N�r 1 Total Depth $�•5 <br /> W 03 -4- Screen Length (from) (to <br /> Well No.: Filter Pack (from) (to) <br /> I \\(rnn pp � Bentonite (from)_S (to) .0 <br /> Inspector: w4e� \ Grout (from),-0 (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. f L I.D. IV <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: .n•e <br /> ij <br /> Driller: casing j <br /> height ? <br /> Consultant JffT <br /> Geologist��S� / <br /> ABOVE-GROUND <br /> OOMPLErION CHRISiY BOX <br /> SPECIAL PERMIT INFO. Ground SuAact COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) S fj <br /> If yes, location and distance - n' <br /> S7-(n. n. <br /> N _ <br /> F � 0 <br /> O <br /> SAMPLING <br /> $to v _ <br /> •*don <br /> Holding Temperature <br /> Method <br /> = �"�D <br /> Screening Method :x <br /> Tracking Sheet - (y/n ) — <br /> a. <br /> �n. 5• n. <br /> SPOILS 5AfA P <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) t <br /> Storage Location Casing e�r <br /> Blank t*OC- ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water ZZ' Bags sand/gravel <br /> Mix Ratios Filter Pack0011,0gist: <br /> ' 2:117,- <br /> Installation <br /> 11i <br /> Installation Method Surge Blocn) (� <br /> Ouantity installed Discussed -V /n ) <br /> 4.30.94• PRaKvA wj 12" 4u jer s Type of method <br /> h02W n 5u't'1.5 lM TK# CWVA5 t Oen k c/ <br /> •� �R,ts Owl rW 4u s u6 vucJ. p <br /> -(ho, (I V4LP_✓KA,'wd Of tkO ccLS t n7 <br /> `l:� Pv16t•n5 Tire OLJ" -t reav-111(rIg <br /> W1 0-Ir !ya'uf9n ncn Sec °'�5 � <br /> KO-1-P P t lemK ? . - ® 4�° <br />