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-rvIONITORING WELL INSTALLATION REPO• <br /> 0— !0 3 �� �i CONSTRUCTION <br /> Date: �b <br /> /LS S, c. Total Depth / (to) <br /> Premise Address: Screen Length (from) <br /> Filter Pack (from) tto) <br /> Well No.: `^ Bentonite (from)(to) <br /> / Grout (from) (to) O <br /> Inspector: v" Drilling rig type <br /> syyyb Auger O.D. �—Cp S'- LD <br /> Permit No. Completion - Stove pipe/chnstie box (circle one) <br /> Drilling Company:�14�1A -4 <br /> .moi <br /> //J_- _M. O / / casing <br /> Driller: r,�G �c- height <br /> � rj <br /> Consultant �p//�,, <br /> Geologist Ch "'^— AgoyE-GROUND L CHRSTy goX <br /> 00WLETION �$ COMPLETION <br /> nd Surf <br /> SPECIAL PERMIT INFO. 8 no� grout <br /> Distance to sewer line -g. <br /> Domestic well on site . (yam g. <br /> If yes, location and distance - n <br /> = m <br /> 0 <br /> _ c <br /> SAMPLING taction $ <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) b <br /> SPOILS �$ <br /> MATERIALS/DEVELOPMENT <br /> Storage Method to <br /> Contamination Noted - (y/ n ) Casing type 0 <br /> Storage Location Blank ft. Screen l0 ft. <br /> Slot size <br /> GROUTING Bags cement 70-4 <br /> Buckets bentonite 77— <br /> Bags <br /> Bags sand/gravel <br /> Depth to water } Filter Pack type/size lZ <br /> Mix Ratios 795'c. Surge Block: - (y/ n ) <br /> Installation Method- h" �� Discussed with geologist: • (y/ n) <br /> Quantity Installed_ Type of method <br /> EH 29 29 <br /> p t <br /> �, 1�5 i flfi 08 a-� <br />