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IMONITORING WELT. INSTALLATION REPOhq <br /> Date: / 73 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �j IA-4,3 Filter Pack (from) (to) <br /> Bentonite (from) 7 (to) .b <br /> Inspector. Grout (from) 3.o (to) E w <br /> Drilling rig type S <br /> Permit No. _�Z __ Auger O.D._ f'7� 1.D. <br /> ' 7d7 Completion - Stove pipe/christie box (circle one) <br /> Drilling Company. <br /> Driller: ' C' casing <br /> p height <br /> Consultantol <br /> (/�/() <br /> Geologist -- <br /> ABOVE-GROUND CHRMY4= <br /> COMPLETION CCMPLETICN <br /> SPECIAL PERMIT INFO. Ground 5urfacs <br /> Distance to sewer line f QfOwt <br /> Domestic well on site - (y On <br /> 0 <br /> If yes, location and distance - f L <br /> M <br /> R. <br /> SAMPLING slorod _ c <br /> Y% <br /> •wM r.r �Y7 <br /> &*clCA <br /> Holding Temperature 4,)14Pack <br /> Method <br /> Screening M shod <br /> Tracking Sheet - (y/ n') <br /> SPOILS <br /> Storage Methodd'�t 'r of d �'�"` '�`'y MATERIALS_,/DEVELOPME_NT <br /> Contamination Noted - y n ) <br /> Storage Location cam. Casing t7e *p()C,/ <br /> Blank ft. Screen <br /> Slot size 10 <br /> GROUPING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Qom_ Filter Pack type/size a !� <br /> Installation Method .�zL - -z e v tue Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />