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MONITORING WELL INSTALLATION REPO <br /> Date: J '40 a CONSTRUCTION <br /> Premise Address: 1/0/tQ ,,'' / • Y� Total Depth iR5 <br /> JA <br /> / Screen Length (from) i (to) ee 0 <br /> Well No.: W s Filter Pack (from) 910 (to)_ Sr8 <br /> Bentonite (from) Sg (to) 56 <br /> Inspector: Grout (from) (to) 6 <br /> Drilling rig type Atf-PI*A?') <br /> Permit No. �� U Auger O.D. W-- I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: � � nl_'�Driller: ( •CCK 7 ` /Pcasing./!�. GiheightConsultant Geologist - <br /> ABOVE-GROUND CNAISTY BOX <br /> COA�LEiION COMPLETIO <br /> SPECIAL PERMIT INFO. Ground Saiaca <br /> Distance to sewer line NRgrout <br /> Domestic well on site - (y/n <br /> If yes, location and distance - ft. <br /> 4D ft. <br /> — m <br /> a <br /> SAMPLING clotted :µ = <br /> wctlan <br /> Holding Temperature <; <br /> Pack <br /> gra <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> Lft. _ ft. <br /> SPOILS <br /> S <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) p r1 <br /> Storage Location Casing type <br /> Blank 6 ft. Screen l5 ft. <br /> Slot size . (316 <br /> GROUTING `Bags cement / <br /> Buckets bentonite �° > <br /> Depth to water 2 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size 12— <br /> Installation <br /> LInstallation Method Surge Block: - (y '— ,� <br /> Quantity Installed Discussed with geo ogist: - (y V <br /> Type of method <br /> EH 29 29 <br /> 1 <br /> U16 Z,s /0x-� <br />