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MONITORING WELL INSTALLATION REPOni <br /> Date: Zii/ <br /> CONSTRUCTION <br /> Premise Address:_ <br /> ,'/ Total Depth Z$ <br /> Well No.: IGv'I YkeL /Uj- 3 Screen Length (from)—?J—(to)— <br /> BentFiltePack (from) Z$ <br /> Inspector: —A(to) /� <br /> Bentonite (from) /1— <br /> Grout (from) /off sS (to) io <br /> Permit No. ����35 Drilling rig type (to) o <br /> Auger O.D. <br /> Drilling Company: � — I.D. <br /> Completion - Stove pipe <br /> / <br /> christie box <br /> (circle one) <br /> Driller: , <br /> casing <br /> Consultant �-GGtCP height T <br /> Geologist <br /> ABOVE-GROUND <br /> SPECIAL PERMIT INFO. COMPLETIONTi ,�� �W'-Sox <br /> / COMPLETION <br /> Distance to sewer line %lOcl � � Z 3 <br /> Domestic well on site - (y n �� I Suiace 0�0"� QS /o <br /> If yes, location and distance / <br /> ft. <br /> 3 ft 2, ft. <br /> — m <br /> SAMPLING <br /> clotted <br /> Holding Temperaturepo�ttit�. soctlon = _ S <br /> Method — <br /> Screening Method <br /> Tracking Sheet - (y/n ) <br /> SPOILS ft' ft. <br /> Storage Method dS � <br /> Contamination Noted - y/ n MATERIALS/DEVELOPMENT <br /> Storage Location « � �f <br /> Casing type � e <br /> Blank— /3 ft. Screen /S g, <br /> GROUTING Slot size O <br /> Bags cement 3 <br /> Depth to wa[er , j`gq�(ti Buckets bentonite <br /> Mix Ratios_ ,, . _ Bags sand/gravel SO <br /> Installation Methods Filter Pack type/size 3 <br /> Quantity Installed / =Z3 , Surge Block: - (y n <br /> ecaC Discussed with geologist. - ( n ) <br /> EH 29 29 Type of method <br />