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• 40NITORING WELL INSTALLATION REPP <br /> / <br /> Inspector: GroutCONSTRUCTION <br /> Premise Address: Ae-4 A- 444f-d / �•Q"�✓ Total Depth �y <br /> Well No.: ��W���j Screen Length (from) 2'S (to) S <br /> Filter Pack (from) Z` (to)�_ <br /> Bentonite (from) (to) b <br /> (from) (to) <br /> as,/J�3� Drilling rig type �1L fC( 7 <br /> Permit No. `J� Auger O.D. Q I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: /, f <br /> Driller: casing <br /> �! / <br /> Consultant �;•P•fttf'�c-"� 3ff T <br /> height <br /> Geologist — �ecica . <br /> ABOVE-GROUND <br /> COMPLETION CHRLM-BOX <br /> SPECIAL PERMIT INFO. p=nd gwfxy COMPLETION <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) ft <br /> If yes, location and distance - <br /> ft ft. <br /> _ m <br /> N <br /> O <br /> C <br /> SAMPLING slattad = c <br /> sarion <br /> Holding Temperature <br /> Method = vavol pack <br /> Screening Method <br /> Tracking Sheet - (y/ n ) ' — <br /> Z 3 ft, _ tL <br /> SPOILS /^�J _ - , p ' 5Z $erJT <br /> l� <br /> Storage Method oa-C ba / <br /> MATERIALS/DEVELOPMENT <br /> Con4amivaden Noted - (y/ n ) Zt Sc)- JC <br /> Storage Location Casing type Ao <br /> Blank $ ft. Screen--Jt—ft. <br /> Slot size .010.t <br /> GROUTING Bags cement 41q i[.3 <br /> Buckets bentonite 1&uj-- W b"&L-u� �, , .1 16 <br /> Depth to water ti Bags sand/gravel &00 <br /> Mix Ratios `( <br /> -t " Filter Pack type/size t Z <br /> Installation Metho Q _ Surge Block: - (y 40 <br /> Quantity Installed " Discussed with geologist: - (y <br /> EH 29 29 Type of method <br />