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&NITORING WELL INSTALLATION REPA <br /> Date:__ `�3 I l CONSTRUCTION <br /> Premise Address: .LTotal Depth <br /> Well No.: C_.� c _ q �D Screen Length (from)_ a, 1 b (to) -10 > <br /> __L Filter Pack (from) (to) <br /> Inspector. �wl �� Bentonite (from)���'���'`����(to) b <br /> . Grout (from) (to) ,occ� � <br /> qa_ (T, Drilling rig type <br /> Permit No._ f I lJ Auger O.D. II.D. <br /> Drilling CoCompletio - S ove pipe/gltristle boa (circle one) <br /> mpany: m <br /> 1 <br /> Driller: ' easing <br /> Consultant <br /> height <br /> Geologist Cj aw`A <br /> ABOVE-GRCOND <br /> COWLETION CHRZrY480X <br /> SPECIAL PERMIT INFO. CCMPLEnCN <br /> �•�Ground Surtaa <br /> Distance to sewer line SC grout <br /> Domestic well on site - (y/ n) <br /> If yes, jpcation and distance - (� �' ft. <br /> SU <br /> E SAMPLINGdona:1.Ozn <br /> Holding Temperature MethodScreening MethodTracking Sheet - (y/ n ) �V f1. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) n <br /> Storage Location Casing type — <br /> �� Blank_.-L00 ft. Screen L% ft. <br /> GSlot size <br /> ROUTING <br /> Bags cement_ 7177- <br /> C Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios V Filter Pack type/size <br /> Installation Method n Surge Block: - (y/ n ) <br /> Quantity Installed_ n Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />