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MONITORING WELL INSTALLATION REPOnf <br /> Date: ' CONSTRUCTION <br /> 2� �� <br /> Premise Address: � Total Depth <br /> // Screen Length (from) /S (to) 2 <br /> Well No.: �� –1� l7 Filter Pack (from) 1"i (to) z�— <br /> '' Bentonite (from) 10 (to) <br /> Inspector: Grout (from) 0 (to) l O <br /> t J ! Drilling rig typeo)'1 — <br /> permit No. S2CO–lC)J60 Auger O.D. I.D. <br /> f 1 , 1 I Completion Stove pip christle box (circle one) <br /> Drilling Company: W f-1-- :2a <br /> Driller: ing <br /> 8 5� � height <br /> Consultant <br /> �lc 39. 5 <br /> Geologist <br /> ABOVE-GROUND CHA1S'P!BOX <br /> COMPLETION COMPLEnCN <br /> SPECIAL PERMIT INFO. Gond Saiacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) 10 ft <br /> If yes,location and distance - <br /> .l�ft. <br /> = m <br /> C <br /> SAMPLING N/k <br /> dotted .%i c <br /> sac�an _ <br /> Holding Temperature = pawl pads <br /> Method — <br /> Screening Method <br /> - Cy/ n)/n) i <br /> Tracking Sheet 4 <br /> = <br /> y <br /> 25 ft, Ir <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noled - (y « � Llp) <br /> Storage Location N[i– Q Casing type <br /> Blank / ft. Screen /O 19 <br /> Slot size O 0 " <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios .ti O ✓` Filter Pack type/size ai <br /> Installation Method tes a Surge Block: - !�n ) � , <br /> Quantity Installed Discussed with geologist: - n) <br /> Type of method <br /> EH 29 29 <br />