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&ONITORING WELL INSTALLATIONUA <br /> Date: �l// n CONSTRUCTION l <br /> Premise Address:—1(g2 �-l- � Total Depth l <br /> Screen Length (from) (to) <br /> Well No.: �7-Z Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) SFS' ' .. (to, A <br /> Drilling rig type <br /> Permit No. Auger O.D. a'% I.D. <br /> Ill Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company:, <br /> Driller: f casing <br /> � J r height <br /> Consultant ( 7.X-O iA GQ-t f —qVT <br /> Geologist / ABOVE-GRCUND <br /> v COW LETION COMPLETICN <br /> GOMPLETICN <br /> SPECIAL PERMIT INFO. �Gfound Saiacs + ��� <br /> grout <br /> Distance to sewer line 1 <br /> Domestic well on site - (y/ n S . ft. <br /> If yes, location and distance-- ft. <br /> —ft. <br /> vA m <br /> a <br /> o <br /> Dept* SAMPLING abrt = c <br /> !/ aor'cn <br /> �S Holding Temperature <br /> Method /3 4 i <br /> r^ <br /> JO Screening Method <br /> Tracking Sheet - Cy/ n ) ..Y.. <br /> , <br /> A" ft. tt. <br /> 3S SPOILS <br /> �0 Storage Method SS dxt� � MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n ) <br /> Storage Location(4.—, , D 5E t 176V v r.P ^ Casing type A//14 <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed 3 Discussed with geo p s: - y n) <br /> Type of method <br /> EH 29 29 <br />