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O")NITORING WELL INSTALLATION REPO!I <br /> Date: (O – 7– 1 0 CONSTRUCTION / <br /> Premise Address: /�GGGotQ, l �Q !�� Total Depth%type <br /> �� Screen Len ) (to) <br /> Well No.: Filter Pack ) (to) <br /> Bentonite ) (to) <br /> Inspector: Grout ) �to)�— <br /> ���pp / /_ / Drilling rigPermit No. dK (P (UIO Auger O.D. I.D. <br /> y C Completion - Stove pi�pe/christie box (circle one) <br /> Drilling Company: / C <br /> Driller: <br /> (Mmnd <br /> Consultant <br /> Geologist G1 ' � `i CNAISTY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. I <br /> Nj� grout <br /> Distance to sewer line <br /> Domestic well on site - (y( 37 ft. <br /> If yes, location and distance - 3� ft. <br /> = m <br /> — n <br /> m <br /> SAMPLING slotted <br /> / socton = -- <br /> Holding Temperature — a"R " Gvo _ Pad� <br /> Method <br /> Screening Method — t` <br /> Tracking Sheet - ( y/ n) <br /> `f tt. ft• <br /> S <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT n !n <br /> Contamination Noted - (y/ n ) aa ' <br /> Storage Location Casing type J <br /> Blank _ft. Screen -f h• <br /> Slot size OI U <br /> GROUTING Bags cement <br /> r 7 Buckets bentonite 7 2 <br /> Depth to water ?' Bags sand/gravel d <br /> Mix Ratios – fi Filter Pack type/size Z <br /> Installation Method r eoC Surge Block: - (y n'. ^, <br /> Quantity Installed r Discussed with geologst: - (y n <br /> Type of method <br /> EH 29 29 <br />