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MONITORING WELL INSTALL-ATlON REP-rLT <br /> CONSTRUC-FrON <br /> Dale: <br /> j oral <br /> ?remise Address:I L Screen Length (from) — <br /> _ Filter Pack Cfrom) <br /> Well No.: Bentonite (from) (tO) <br /> Vv Grout (fram) (to)_ <br /> Inspector. Drilling rig We- <br /> 4L <br /> e <br /> Auger O D. 13. <br /> Permit No. , Completion - Stove pipe/cnris3e box (circle one) <br /> Drilling Company: 'L ,IO <br /> 1�' t cas i zg <br /> Driller. height , <br /> Consultant <br /> Geologist ��� ear` ASGVE-•��CVND p-�F1tS�"�'-aOX <br /> compt ICN <br /> Ground Surf2as <br /> SPECIAL PERMIT INFO. <br /> 15 Distance to sewer line W z 3 T _ <br /> Domestic well on site - ( y/ n ) IL <br /> I <br /> If yes, location and distance - � ! <br /> 32- 10 ' <br /> gtonad y <br /> SAMPUNGto F 3 <br /> O s P <br /> ack <br /> Holding Temperature <br /> Method r Screening Method <br /> 7rackin Sheet - ( Y/ a ) (3� _ fL <br /> g N <br /> SPOILS <br /> MATERIALS/DEVELOPNENT <br /> Storage Method <br /> Contamination Noted - (Y/ n Casing type <br /> Storage Location Blank ft Screen_—.— <br /> Slot size <br /> Bags cement <br /> GROLMNG l Buckets bentonite <br /> (� ` �� Sags sand/gravel <br /> Depth to water—LL <br /> "U ` Filter Pack.type/size ---�— <br /> Mix Ratios GAY,, Surge Block: - y n } <br /> Installation Method "7 Discussed wit gologur ' ( Y/ n) <br /> Quantity Installed �+_ Type of method <br /> FH 29 29 <br />