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100NITORING WELL INSTALLATION REPA <br /> Date: 1 I t 4 l i D <br /> / CONSTRUCTION <br /> Premise Address: Q b� � „� r2 Total Depth <br /> A2c �S <br /> Screen Length (from) ( S (to) <br /> Well No.: I^ W 3 Filter Pack (from) rt- S (to) 4?— <br /> Bentonite (from) R.� (to) 17 <br /> Inspector: �r r(rr��( Grout (from) q.; (to) o <br /> Permit No. <br /> S )A- S g� �1 Drilling rig type r,> <br /> rl/ r— Auger O.D. ,Z¢ I.D. <br /> r <br /> Drilling Company: <br /> Completion - Stove pipe/ s de box (circle <br /> � T fv� <br /> Driller: C rr"77 ^Z�a�� L casing <br /> n height <br /> Consultant_ <br /> Geologist_ <br /> ABOVE-GROUND <br /> OO&FLETION C4-s <br /> SPECIAL PERMIT INFO. COMP ON <br /> Ground Sumacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - 1 ft. <br /> ft ft. <br /> — m <br /> — e <br /> SAMPLING <br /> Qti alortad 'c <br /> "cion — B <br /> Holding Temperature — <br /> Method_ gravel pack <br /> Screening Method <br /> Tracking Sheet - (y/ n) _ <br /> SPOILS <br /> Storage Method 1/0 �.z tij i h wt Aw5 iL MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n f V-&-kc <br /> Storage Location__0 Casing type DV t, Las r� <br /> Blank_ (� fr.— Screeny3o SI-e, ft. <br /> Slot size 27 e)5J <br /> GROUTING <br /> Bags cement q v g.v;2 <br /> Buckets b <br /> Depth to water Z t)` h5 `�} 1 Aµt Bags sand/gravele �q4(b Ban) <br /> ti <br /> Mix Ratios Filter Pack type/size r lx� W (.rwrSc_ <br /> Installation Method \A S Ru w•(7 Surge Block: - ( y/ n ) <br /> Quantity Installed T <br /> Discussed with geologist: - ( y/ n ) <br /> EH 29 29 Type of method <br />