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MONITORING WELL INSTALLATION REPOxi <br /> Date: 1115.0 So CONSTRUCTION �f� <br /> O <br /> Premise Address: /d 0 D U/. M Total Depth T <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to)_ <br /> Bentonite (from) (to) Z <br /> Inspector: Grout (from) (to) <br /> i/Cf3 Drilling rig type <br /> Permit No. �f 0 / Auger O.D. 1 I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: - j casing <br /> /'X height <br /> Consultant Lf /� <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION <br /> COMPLETON <br /> SPECIAL PERMIT INFO. Ground Surf <br /> Distance to sewer line 5Q� grout <br /> Domestic well on site - ( y G <br /> If yes, location and distance - ft. <br /> Ott. b tt. <br /> _ <br /> — m <br /> — e <br /> = m <br /> SAMPLING slotted = £ <br /> �? /k F� Ca.fc�z 3s�yo' sacion <br /> Holding Tature = _ <br /> Method v'viW pack <br /> Screening Method <br /> Tracking Sheet - y nLQD <br /> ) — <br /> tt. <br /> SPOILS7U <br /> 54" <br /> Storage Method UIL f"~&t l/" MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y�Z A 2 t. n <br /> Storage Location gt4o Scy� Casing type e �` <br /> Blank (05 Screen fr. <br /> Slot size O a ii <br /> GROUTING Bags cement p <br /> / Buckets bentonite Y <br /> Depth to water Bags sand/gravel <br /> Mix Ratios 2: Filter Pack type/size Z 1Z- <br /> Installation Method Surge Block: - (ynn <br /> Quantity Installed S5 t Discussed with geologist: - (y <br /> Type of method <br /> EH 29 29 <br />