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5 <br /> UONITORING WELL INSTALLATION REP(�d <br /> i <br /> Date: �' �� '�� CONSTRUCTION V W L +VO Z <br /> Premise Address: 2L 1 T�C_ Total Depth 3S <br /> Screen Length (from) 3 S (to) IS <br /> Well No.: V\ { VyJ 2- Filter Pack (from) `3� (to) 13 <br /> Bentonite (from) 13 ` (to) NO <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: nsk . ( <br /> r���tw1 Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant_ �J <br /> Geologist ­�ly\ CueLLC-A •� <br /> ABOVE-GROUND CHRM Y-BOX <br /> P+p�Pn►� GOMPLETION GOMPLETION <br /> SPECIAL PERMIT INFO. �t Y,2 C�vur�d Surfacr <br /> Distance to sewer line N 5' �' NA ori ; <br /> Domestic well on site - (Y/ ro' NIN {1�pc o ft. <br /> If yes, location and distance - 15, � l LA <br /> NA <br /> ! 231, 4 <br /> 15 6Dmt 4CA <br /> .r 4 <br /> Y �11 I® 25l Fee-,,,-Porgy — <br /> �p rrifltisty✓� �� <br /> c Y <br /> SAMPLING .5 •Iostsd <br /> 5 3 socdon <br /> Holding Temperature Are– '• _ <br /> sr: — gravel Pads <br /> Method (R <br /> k> <br /> Screening Method LL> <br /> Tracking Sheet - (y/ n <br /> ft. <br /> SPOILS µ�2 `• ' • <br /> Storage Method �1 Lc- YW Z &TERIALS/DEVELOPMENT <br /> Contamination Noted - / n ) <br /> Storage Location E9.In tke W cga Casing type 12-r+ �yG S�� 40 ' <br /> Blank t 5 ft. Screen Z C> ft. <br /> + Slot size . D 2 <br /> GROUTING ® ,� 0.5 K\O S Bags cement <br /> Coram �'� Vwcis Buckets bentonite <br /> Depth to water Bags sand/gravel 5 `7( <br /> Mix Ratios Filter Pack type/size i <br /> Installation Method ti 1�`4 Surge Block: - (y/ <br /> Quantity Installed +} T� 1 Discussed with geopokist: <br /> F Type of method far <br /> 4 EH 29 29 Lk+-tL,. Carsc r-s <br /> l�et9 +au( inti-e 05A -tt)cc,c rctoc� <br />