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'MONITORING WELL INSTALLATION REPCI L <br /> 5- <br /> /u <br /> Date:— <br /> �/�K�� G-(O-oe CONSTRUCTION <br /> � q <br /> Premise Address: d Total Depth !S <br /> // .� Screen Length (from) �3 (to) 6 S <br /> Well No.: Qi1 Filter Pack (from) % (to) — <br /> Bentonite (from) G3 (to) 4 O <br /> Inspector: Grout (from) loci (to) a <br /> Drilling rig type b Z <br /> Permit No. Z'T / Auger O.D. V I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Compaany:: /�E w <br /> / <br /> Driller: A-� -r ti""`— casing <br /> height <br /> Consultant ,,// ,^, 0Q T <br /> Geologist / 1 •- T <br /> ABOVE-GROUND CNRISIY-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground SuAace <br /> ? Qrart <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) v <br /> If yes, location and distance - ft' <br /> h3 n. <br /> -- o <br /> C <br /> SAMPLING slotted <br /> sec�on <br /> Holding Temperature = gravgl Pack <br /> Method 82 = <br /> Screening Method <br /> Tracking Sheet - (y/n ) <br /> �ft. = ft. <br /> SPOILS 95 77foo <br /> Storage Method W C�l t�A MATERIALS/DEVELOPMENT <br /> Contamination Note - (y n u �� <br /> Storage Location Casing type <br /> Blank ft. Screen &. <br /> Slot size • oto, <br /> GROUTING Bags cement <br /> Buckets bentonite S V7- <br /> Depth to water = Bags ;nd 'avel 50� <br /> Mix Ratios Z t U - Filter Pack type/size 12. <br /> Installation Method Surge Block: - (y n <br /> Quantity Installed /A'e.✓ Discussed with geo ogist: - (y n <br /> Type of method 1AA4L ' <br /> EH 29 29 <br />