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NITORING WELL INSTALLATION REPOP'" <br /> Date: I (� I l J CONSTRUCTION <br /> I TCck' �JPremise Address• lAJ Total Depth S <br /> Screen Length (from) 'A -q (to) I$ <br /> Well No.: LJ Filter Pack (from) (to) <br /> r Bentonite (from) (to)� <br /> Inspector. Grout (frgm) t (to) <br /> Drilling rig type <br /> Permit No. © 6 Auger O.D. // ' I <br /> L� <br /> Completion - Stove pipe/ tie bos circle one) <br /> Drilling Company:�X.��D(c�� iJ� L)e-&5 IL)IccS <br /> Driller.Drille <br /> height <br /> Consultant <br /> Geologist -�� 71//' <br /> AiCVE"G8CUNp <br /> C.:hFC.:l;CN Ci�ilS'T`1-30X <br /> CCMPU=T1CN <br /> SPECIAL PERMIT INFO. G=nd Srf <br /> gram <br /> Distance to sewer line F ' <br /> Domestic well on site - ( y/ n ) ft. <br /> If yes, location and distance - n- <br /> 15 ;t. <br /> = s <br /> SAMPLING siorai <br /> sec"on — <br /> Holding Temperature _ - vivo'Pack <br /> Method <br /> Screenin;Method <br /> Tracking Sheet - ( y/ n ) <br /> IF - T- S M <br /> SPOILS <br /> Storage Method S C MATERIALS/DEVEI.OPMENT <br /> Contamination Noted - (y/ n1 <br /> Storage Location_�� � >r\ 1ti�1U- Casing type <br /> Blank fr. Screen ft. <br /> Slot size E©---2- <br /> GROUTING Bags cement <br /> Buckets bentonite =�- <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size t?r`L k 54ar- 3 <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />