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MONITORING WELL INSTALLATiOreyORT <br /> Date: <br /> CON�ON <br /> Premise Address:/��fl�� <br /> Total Depth Zp <br /> Well No.: Screen Length (from) t o <br /> Filter Pack (from)—T— (to)� <br /> Inspector. � 'I ��8 Bentonite (from) (10) (� <br /> Grout (from)— (to)�— <br /> Permit No. Z3 3` ( Drill* ri —(i0) <br /> 3 g type <br /> Auger O.D. <br /> • nP I.D.Drillin company-_ Completion-- <br /> boz (circle <br /> Driller. <br /> _ casing <br /> Consultant 14 1&-t Ly�(/� height <br /> T7M <br /> Geologist 1.� es <br /> V_ <br /> APCVE•GacuND <br /> SPECIAL PERMIT INFO. OO&PLE lON CMM-BOX <br /> Cxu:rc1 Strfacs T__ <br /> tq <br /> Distance to ;ewer line —` <br /> Domestic well on site - (Y/n) grout <br /> If Yes, location and distance <br /> ' ft. <br /> SAMPLING = o <br /> Holding Temperature ilorndsoelon •; � <br /> Method = <br /> Screening M od — gravdyack <br /> Trackin cet - (Y/n) i <br /> SPOILS <br /> Storage Method <br /> Contamination Noted - (;Y n, MATERIALS/DEVE I OPMENT <br /> Storage Location p �o <br /> Blank type_ <br /> GRA #k I n ft Screen - �fr. <br /> Slot sue p1c2 <br /> Bags cement <br /> Depth twater tit y ' Buckets bentonire <br /> Mix Ratios Bags sand/gravel <br /> Installation Method Filter Pack type/size_ z <br /> Quantity Installed <br /> Surge Block: - W n ) <br /> EH 29 Zq <br /> Discussed with geologist: - ((y� n) <br /> Type of method <br />