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MONITORING WELL INSTALLATION REPOIP <br /> Date: I ffU44 �Z/`//O��(�/l CONSTRUCTION <br /> Premise Address: /0O 0 /.�, ((Il�%�• s Total Depth /,go <br /> �// Screen Length (from) $ (to) SS <br /> Well No.: Filter Pack (from) (to) 5V <br /> Bentonite (from) (to) 5/ <br /> Inspector: S Grout (from) 51 (to) 9 <br /> Drilling rig type C4-6 -45 <br /> Permit No. uQ U Auger O.D. K I.D. <br /> ! Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: 1= el A Q <br /> Driller: /� casing <br /> //C_ height <br /> Gf' <br /> Consultant <br /> Geologist[- 4lC f S — V- <br /> 4 <br /> ABOVE-GROUND <br /> COMPLETION CHRlSTY <br /> C ON <br /> SPECIAL PERMIT INFO. G=rd Surlace 7— <br /> Distance to sewer line /,-5c) 7rout <br /> Domestic well on site - ( �� <br /> If yes, location and distanc-r-- n' <br /> n. <br /> = m <br /> o <br /> — m <br /> C <br /> SAMPLING dotted = c <br /> &octan <br /> Holding Temperature <br /> Method 9"�Pack <br /> Screening Method r> <br /> Tracking Sheet - (y/ n ) <br /> •sg n. = n. <br /> SPOILS _ <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) I/ n ✓n ` <br /> Storage Location Casing type j/ 1.., LfO <br /> Blank fr. Screen <br /> Slot size .0/ <br /> GROUTING B�cement o �� ti0 5 = LS1C =�) <br /> Buckets bentonite! 2 P <br /> Depth to water % L Bags sand/gravel <br /> Mix Ratios 2atR,F y0 Filter Pack type/size Z. <br /> Installation Method 1 /,I Surge Block: - (y <br /> Quantity Installed�jj5 / 2,5not Discussed with geoogist: - (y <br /> Type of method <br /> EH 29 29 <br /> lakll4 ('1 AS, � / <br />