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)NITORING WELL INSTALLATION REPC <br /> Date: ✓ 4/ CONSTRUCTION <br /> i <br /> Premise Address: Total Depth 9- <br /> Screen Length (from) 75' (to) S <br /> Well No.: �� 7 Filter Pack (from) 75 (to) <br /> Bentonite (from) (to) <br /> Inspector: .I Grout (from) (to) <br /> q� Zl f •� Drilling rig type I� S� <br /> Permit No. Auger O.D. $ I.D. /y <br /> Q Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: f' <br /> Driller: casing <br /> height <br /> Consultant17 T <br /> /��� <br /> J J ► - <br /> Geologist .�J� ABOVEGROUND <br /> COMPLETION CH ISTY�X� <br /> l NN <br /> SPECIAL PERMIT INFO. Ground Surlacs <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - ( y/ ft. <br /> If yes, location and distance - ft. <br /> ..�Lft. <br /> = m <br /> = m <br /> — r <br /> — c <br /> — o <br /> SAMPLING slotted <br /> vection <br /> Holding Temperatures G2wc t � � gravel Pads <br /> Method <br /> Screening Method �• A- <br /> Tracking Sheet - .Y�' n ) <br /> -76 ft. L 4===—Jft. <br /> SPOILS <br /> Storage Method . �s MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) L �LI/� <br /> Storage Location c7m Casing type <br /> Blank ft. Screen 3o ft. <br /> Slot size .0 2- <br /> GROUTING <br /> GROUTING Bags cement <br /> 2 / Buckets bentonite <br /> Depth to water �7•.7 Bags sand/gravel <br /> Mix Ratios 49Filter Pack type/size2 L•S. <br /> Installation Method U ULL Surge Block: ( yn <br /> Quantity Installed Discussed with geologist: - yon ) <br /> Type of method <br />