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46ITORING WELL INSTALLATION REP* <br /> Date: D 3 CONSTRUCTION <br /> Premise Address: LA t ' �) C Total Depth 53 <br /> Screen Length (from) (to)�_ <br /> Well No.: Filter Pack (from) (to) .— <br /> Bentonite (from) (to) <br /> Ins ector. � Grout (frpm) (to) <br /> P h�t�rn <br /> q Drilling rig type <br /> Permit No. <br /> �3- Auger O.D. <br /> Completion - Stove pipe/ 'stie box ircle one) <br /> Drilling Company: <br /> Driller: casing <br /> t height <br /> Consultant_ es fp <br /> Geologist �k/n 0-6 ^=D ABOVE-GROUND <br /> COMPLETION Ci1ON <br /> COMPLETION <br /> SPECIAL PERMIT INFO. G=r d Surt'a +��-^ <br /> PIR grout <br /> Distance to sewer line <br /> Domestic well on site - (y n' S fie <br /> If yes, location and distancett. <br /> .�.n. <br /> p � <br /> V � + <br /> Q <br /> SAMPLING .brei <br /> socion <br /> Holding Temperature = Gf1°I pack <br /> Method <br /> Screening Method P LL _ <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT\ <br /> Contamination Noted • y Casing type <br /> n ) a /( 3 y C- <br /> Storage Location <br /> Blank ft. Screen 2"t] ft. <br /> Slot size <br /> GROUTING Bags cement S o <br /> Buckets bentonite <br /> Depth to water - Bags sand/gravel <br /> Mix Ratios __ Filter Pack type/size <br /> Installation Method Surge Block: - (y/(9 <br /> Quantity Installedr Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br /> l0 - ( - � w <br />