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a„�.WITORING WELL INSTALLATION REPOA - <br /> Date: CONSTRUCTION MWOttM M+ti, 2 <br /> Premise Address: Total Depth & r$ <br /> Screen Length (from)C9-0' t !?' (to) ' <br /> Well No.: Filter Pack (from) /9 ' (to} ' <br /> Bentonite (from).? (to) 1 i <br /> inspector: �; Grout (from) i (to) <br /> Drilling rig type ` <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipeJciuistie box (circle one) <br /> Drilling Company: �' <br /> Driller. ca9 inq <br /> height <br /> Consultant �- <br /> Geologist — <br /> 76- <br /> ABOVE-GRGUND crostm-aOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Suiaas <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - �- <br /> «c' <br /> SAMPLING 910ro.'1 <br /> sedcn <br /> Holding Tempera <br /> µ <br /> Method Pack <br /> Screening Method <br /> Tracking Sheet - ( y/ n) <br /> ..eft. ter. `w ft- <br /> SPOILS <br /> Storage Method MATERIALS,/DEVELOPMENT <br /> Contamination Noted - {y/ n ) `r [. <br /> Storage Location CasingPeg <br /> Blank 53 ft. Screen / ft. <br /> Slot size_ G 2 D <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depthto water Bags sand/gravel,_ <br /> Mix Ratios _ Filter Pack type/size <br /> Installation Method Surge Block: - ( y t i�) <br /> Quantity InstalledDiscussed with geo"lbgist: -�y,/ n) <br /> Type of method <br /> EH 29 29 <br />