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OONITORING WELL INSTALLATION REP(,, <br /> Date: C7^'� 2,61 �,,j//`"/) CONSTRUCTION ! <br /> Premise Address: I !cSV Ka /VGC / Total Depth <br /> a „ Screen Length (from) <br /> Well No.: �' S Filter Pack (from) 6 (to) <br /> 114 <br /> Bentonite (from)�Ro) 3 <br /> Inspector: Grout (from) 3 (to) G' <br /> Drilling rig type <br /> Permit No. cJ/c O/o Auger O.D. 4 I.D. 3 <br /> ' Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: / V C <br /> Driller: casing <br /> IffT height <br /> Consultant iC?�r-+rQLt�s l� <br /> Geologist <br /> ABOVE-GROUND CHSZTY-BOX <br /> COMPLETION COMPLE710 <br /> SPECIAL PERMIT INFO. Ground Su we <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - n ) 3 ft. <br /> If yes, location and distance - -r tt. <br /> a <br /> e <br /> C <br /> SAMPLING <br /> f slottedApe <br /> vection '- <br /> cy <br /> Holding Temperature /+�D`�t D� �'� .09- _ gavel pxk <br /> Method Rpt-► _ <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) s <br /> tt. LJtt. <br /> SPOILS <br /> Storage Method �� cQ MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type y Y <br /> Blank 5 ft. Screen .; ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite a <br /> Depth to water = /sU Bags sand/gravel 6;Z-- <br /> !iL• <br /> Mix Ratios — $ °f Filter Pack type/size e <br /> Installation Method Surge Block: - (y n <br /> Quantity Installed f / Discussed with geo ogist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br /> Ailrl rr <br />