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J � <br /> M <br /> 7VIONITORING WELL INSTALLATION REP6n I <br /> Date: Z L CONSTRUCTION <br /> Premise Address: Total Depth_ <br /> Screen length (from) (to) ?� <br /> Well No.: Z Filter Pack (from) (to) <br /> AN <br /> Bentonite (from) (to) Z <br /> Inspector: _ Grout (from) (to) <br /> f(� Drilling rig type <br /> Permit No. 'rte ! 7 Auger O.D. I.D. <br /> Completion-Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: � Gr*1 f casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE43ROUND CtiRtSTY480X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground sudwe <br /> Dirtahce to sewer line Grout <br /> Domestic well on site - (y n Z5 X <br /> If yes, location and distance - n• <br /> ax �- M <br /> SAMPLING sbt<ad c <br /> • aacdon <br /> Holdingf Temperature /1 <br /> Method �G G'GC C = z: pack <br /> Screening Metho /D = <br /> Tracking Sheet <br /> SpDIhS _ <br /> age hod �' - M�TEItTALS/DE�E);Chh�' <br /> Cont=fn**t,V;ote - (y <br /> Storageucapo type <br /> 1# ° ft. . Screen ft <br /> Slot size _ btl <br /> UT[NG Bags cement <br /> Buckets bentonite <br /> Depth to water 7,- Bags sand/gravel <br /> Mac RatiosFilter Pack typesize <br /> .'t/ <br /> Instxllatiom' tho MeSurge Block: - (y n ... <br /> Quantity In lied ` Discussed with geologist: - (-..yam <br /> Type of method <br /> EH 29'20 <br /> 5� S <br />