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ONITORING WELL INSTALLATION REPO* <br /> Date:j(o /.q'73 /o�j3�53 <br /> Premise Address: p CONSCONS—= <br /> Well No.: Total Depth l S <br /> Screen Length (from) <br /> Inspector � P Filter pack (from) (to) <br /> Bentonite (from) —(to)�_ <br /> Permit No. ��-��jC�3 Grout (from)---�(to)�� <br /> Drilling rig type --- �(to)—_ <br /> Drilling Company j✓ Auger O.D. .b1/y <br /> Completion • Stove I.D._ C iU <br /> pipe/chrisde box (circle Driller._�� <br /> Consultant . .,4 ,S , casing <br /> height <br /> Geologist <br /> SPECIAL PERMIT INFO. ABOVE-GROQND <br /> CONFLETION C iMw Y-BOX <br /> Distance to sewer line ' �� G=rd Swfac* OOWLPTICN <br /> Domestic well on site - (y/n) r <br /> It yes, location and distance - o�ax <br /> ft, <br /> SAMPLING <br /> Holding Temperature oL y 9x4cn = 3 <br /> Method Q — <br /> � c <br /> Screening Method - <br /> Tracking Sheet y)/n) <br /> qs ✓i - s <br /> SPOILS 3D Vj- Sb tt <br /> Storage Method_ - _MATERIALS/DEVELOPMENT <br /> Contamination Noted - y/n ) �G <br /> Storage Location n„ - Sjl . eu >>{ n/ Casing type <br /> BlankZ.� ft. Screen_L/A g, <br /> GROLMNG Slot size o Zo <br /> Bags cement <br /> Depth to water N] Buckets bentonite_ �. <br /> Mix Ratios Bags sand/gravel <br /> Installation Method <br /> Filter Pack type/size $FzI <br /> , Surge Block: - (y <br /> Quantity Installed t Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />