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i / <br /> MONITORING WELL INSTALLATION REPOT . <br /> Date: t /9jep _— CONSTRUCTION <br /> /� <br /> Premise Address : W41 C �v ( �� /� O LLu/9 Total Depth <br /> GtJ Screen Length (from) (to) <br /> Well No. : /� Filter Pack (from) (to) _ <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drillind3 5 Auger <br /> rig type I <br /> Permit No. Au ger O.D. = $ 9 =8 I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: d r casing <br /> height <br /> Consultant_�GG7 <br /> Geologist O r <br /> AOCkVLRWND *COMPLaEnrON <br /> X <br /> COh4'LEIION <br /> SPECIAL PERMIT INFO. 9 , U S64 nd $ui <br /> 2 <br /> Distance to sewer line d � i grout <br /> Domestic well on site - ( y AD � 9Z ft* <br /> ON <br /> If yes, location and distance - J n , <br /> (t. ft. <br /> SAMPLING r '_ - - llra7v <br /> slotlod <br /> I �� asc non .FHolding Temperature L _ In <br /> c._ <br /> Method _ <br /> Screening in Method <br /> Tracking Sheet - ( y / n ) <br /> SPOI14S <br /> Storage Method G` /w MAT) IUALS/DEOPMENT <br /> Contamination Noted - ( V <br /> A % <br /> Storage Location D Casing type 2 <br /> 1 1 S-ok <br /> (, <br /> Blank.ft' Screen, fr. <br /> �± b Slot size <br /> GROUTING e� IT e ti 7rI Bags cement <br /> p Buckets bentonite <br /> Depth to water LBags sand/gravel <br /> Mix Ratios Or o 0- A Filter Pack type/size_ <br /> Installation Me od Surge Block: - ( y / n ) <br /> Quantity Installed ��JLc J�Or� a/ Discussed with geologist: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br />