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i <br /> MONITORING WELL INSTALLATION REP., T <br /> Date: �Qr CONSTRUCTION <br /> Premise Address: -35 Total Depth <br /> I/�1/�/ q Q Screen Length Cfrom) 125{ Cto) I fR <br /> Well No.: b MVV-' - 1 ` Filter Pack (from) lig (to) I I .'C�- <br /> Q F Bentonite (from) 11,E (to) 1I3 _ - <br /> Inspector. V®" Grout (from) 113 (to) <br /> Drilling rig type <br /> Permit No. Auger O D. LD. <br /> < rwh^ Completion - Stove pipe/cbristie box (circle one) <br /> Drilling Company: <br /> Driller. cas ing <br /> I ` U I height <br /> Consultant �J1 I AA' ` ( I ` r � T <br /> Geologist T <br /> A3OVr:-GROUNO c ditSTY30X <br /> CCWLaTION COMP_"Ur-N- <br /> SPECIAL PERMIT INFO. Ground arf'p T�� <br /> n� <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) I�I ^ I 113 L <br /> If yes, location and distance - a I S th <br /> It. <br /> SAMPLING t1Oted <br /> a�aion =' — <br /> Holding Temperature _ <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) ft <br /> �X, <br /> SPOILS Lem' f <br /> Storage Method v/�L —c 4 on 5`7p - «z MATERIALS/DEVELOPMENT Cw4w' <br /> Contamination Noted - n ) @ I I l Z° P U C- g S <br /> Storage Location l J Casing type <br /> Blank L Screen /r- fL <br /> Slot size <br /> GROUTING W S l'Q r ? Bags cement <br /> ''// II Buckets bentonite <br /> Depth to water Cc ^ VJCA'1� L,/CJ ^ �d�lks Bags sand/gravel <br /> Mix Ratios kbje \ Filter Pack type/siz <br /> Installation Method ) Surge Block: - (y n <br /> DiscQuantity Installed Type f t <br /> with geo gis <br /> Type of method <br /> EH 29 29 <br />