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410NITORING WELL INSTALLATION REPO' <br /> Date: ( � 3�Q CONSTRUCTION <br /> Premise Address: Total Depth �05 <br /> �/ Screen Length (from) Z (to) <br /> Well No.: /, Filter Pack (from)----P-5 —(to) 5 8 <br /> Bentonite (from) SS <br /> Inspector: Grout (from) 5�5 (to) 3 <br /> Drilling rig type DhtiE 15 <br /> Permit No. Auger O.D. R- I.D. <br /> Drilling Com <br /> Completion - Stove pipe/christie box (circle one) <br /> Company: <br /> Driller: )�-q wall. casing <br /> � ��p height <br /> Consultant --� 11 <br /> Geologist VA,14� i1jot-& <br /> ABOVE-GROUND <br /> COMPLETION CHRZ7Y-80X <br /> SPECIAL PERMIT INFO. Groundgu�lyy COMPLETION <br /> i <br /> Distance to sewer line 1-1 ad proof <br /> Domestic well on site - (y/ n ) 55 <br /> If yes, location and distance - ft. <br /> — c <br /> SAMPLING slowc <br /> _ <br /> +ec+on <br /> _- <br /> Holding Temperature <br /> Method — graval pack_ <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y 115 <br /> Storage Location Casing type 2 �/. <br /> Blank ft. Screen ft. <br /> Slot size .O/d <br /> GROUTING Bags cement .7-5 Coal <br /> Buckets bentonite / Z <br /> Depth to water Bags sand/gravel <br /> Mix Ratios H70 °` s` Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed 5S 3 }p Discussed with geologist: - (y/n ) <br /> Type of method <br /> EH 29 29 <br /> /' 3,'D 1 <br />