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OITORING WELL INSTALLATION REPOPL* <br /> Date: Ll I CONSTRUCTION <br /> 2�5� C (� � <br /> Premise Address:., a r� Total Depth J �\ <br /> Screen Length (from) y (to) y <br /> Well No.: ) Filter Pack (from) 36 ' (to)� <br /> Bentonite (from) )'L (to) i 4 <br /> Inspector. Y L :I �Re�� Grout (from) / G ' (to) v <br /> 1 Drilling rig type hreL ✓�(z awe, - �7 <br /> Permit No. Auger O.D. I.D. i <br /> < Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> . r <br /> Driller: �.� casing <br /> _ height <br /> Consultant T <br /> Geologist <br /> IV <br /> ABOVE-GRCUND CS¢i1Maox <br /> =FLEMN CCMPLZnCN <br /> SPECIAL PERMIT INFO. G=nd 3urtr� <br /> Distance to sewer line a `S U oro <br /> Domestic well on site -QY n ) V ft. <br /> If yes, location and distance - i tt- <br /> a <br /> _ m <br /> — o <br /> SAMPLING donwi <br /> saricn <br /> Holding Temperature — caval G <br /> Method __ <br /> ack <br /> Screenin;Method — <br /> 3 — <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method r„ tin MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ . 'I <br /> Storage Location Qr, hS— Casing type h V <br /> Blank 1 ft. Screen <br /> Slot size <br /> GROUTING Bags cement bauo <br /> 1q Buckets bentonite 01 <br /> Depth to water 1 U Bags sand/gravel <br /> Mix Rados 3 Filter Pack type/size __ )2 _-_ ovLea i/C <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />