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"i 0NITORING WELL INSTALLATION REPO# <br /> Date: �7//J�� /G� CONSTRUCTION u <br /> Premise Address: i � Total Depth ION <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) !�i!5r _ <br /> Inspector: <br /> (from) (to) <br /> Grout (from) 7 <br /> _(�) <br /> Permit No. <br /> �L'��N/n p�3 Drilling rig type I.Drilling"-�Y/�`OGJ Auger O.D. LD. <br /> Drilling CompanCompletion - Stove pipe/christie box (circle one) <br /> y: <br /> Driller: C casing <br /> height <br /> Consultant <br /> Geologist_ T <br /> ABOVEGROUND <br /> COMPLETION we tcr <br /> BOX <br /> SPECIAL PERMIT INFO, Ground g� <br /> Distance to sewer line SO grout <br /> Domestic well on site - (y <br /> If yes, location and distance= �Z n• <br /> CD <br /> s n. <br /> m <br /> O <br /> SAMPLING <br /> LG ,y.Q� slotted _ _� 8 <br /> i <br /> an <br /> Holding Temperature t/UL.�— .teaSll�ro0 socr <br /> Method = gr"`iW Pack <br /> Screening Method - <br /> Tracking Sheet - (y/ n ) <br /> 5�ft <br /> SPOILS �O <br /> Storage Method A. £G/ 44sy MATERIALS/DEVELOPMENT <br /> Contamination Noteb( y/ n ) / <br /> Storage Location t *'r QGEw Casing type Z r S� l✓(:f. <br /> Blank . —ft. Screen fr. <br /> Slot size - 0/,0 <br /> GROUTING Bags cement /O t <br /> Buckets bentonite / 30 <br /> Depth to water �Z 77— <br /> Bags sand/gravel / 1- <br /> Mix Ratios ya > "` /a a // y Filter Pack type/size /Z <br /> Installation Meth Surge Block: - (y/ n ) <br /> Quantity Installed 5e Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br /> 1Z1ie/e b �d <br />