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I <br /> MONITORING WELL INSTALLATION REI---cT i t <br /> Date: �✓ �' fear CONSTRUCTION <br /> Premise Address: � U Total Depth <br /> Screen Length (from) (to) <br /> Well No.: /�j— (l Filter Pack (from) (to) <br /> — X [ Bentonire (from) (to) <br /> Ian !/ Grout (from) (to) <br /> Inspector. Drilling rig type <br /> Auger OD. LD. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller-- <br /> r7 <br /> Consultant <br /> GeologisA2 py--GROUND p py5;!.3pX <br /> CCw R"AN COMPL=iON <br /> Ground Stzfxa <br /> SPECIAL PERMIT INFO. /-/ / � <br /> QrI= <br /> Distance <br /> to sewer line 1 <br /> Domestic well on site - / n) _L _ 8. <br /> If yes, location stance - t <br /> ft r __ <br /> 73 <br /> a <br /> SAMPLING <br /> See <br /> J/ trccn <br /> Holding Temperature <br /> Method ' = packI <br /> Scree <br /> Tra g Sheet • ( y/ n ) <br /> ft. <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination.Noted- (Y/ n) Casing type <br /> SCorageEL <br /> �Location Blame ft Screen <br /> Slot size <br /> Bags cement <br /> GROUTING 1 Buckets bento ' e <br /> ZDised <br /> el <br /> Depth to water ti ;an, /size <br /> Mix Ratios C Y/ n ) <br /> Installation Method geologist - C Y/ n) <br /> Quantity Installed EH 29 29A,0 <br />