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.MONITORING WELL INSTALLATION REP i' MM <br /> Date• C(��o f CONSTRUCTION <br /> T* <br /> Premise Address: LDS �� 1�'�-� Total Depth fDU <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack „(from) (to) t <br /> Bentonite (from) (to) <br /> Inspector: .., tr­_Grout (from)_ - (to) - <br /> u Drilling rig type s <br /> Permit Auger O.D. &7-F__ I.D. <br /> } Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller• ..� -�� - casing .� . <br /> �� � height . <br /> Consultant <br /> Geologist l.�- � '� <br /> ABOVE-GROUND CNRMW-SOX <br /> COW-LETION - COMPLEMCN <br /> SPECIAL PERMIT INFO. Gmund Sudact <br /> Distance to sever line _ Qr <br /> Domestic well on site - ( y/n ) a ft. <br /> If yes, location and distance - jArV <br /> SAMPLING w ilaroid _ a <br /> �.. . soen Ott 3rd <br /> Holding Tem erature 7 b� v' .. YS 4 W <br />{. Method l�✓�� ,�---�-�� '�'' <br /> Screening Method <br /> " ,. <br /> Tracking Sheet -�(- n ) <br /> . SPOILS t I .. <br /> Storage Method w MATERIALS/DEVELOPMENT <br />' Contamination Noted - " / n ) r <br /> Storage Location u "'� w .. Casing type <br /> V _ Blank ft. Screen ft. <br /> Slot size <br /> t GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water LZ 6 Bags sand/gravel <br /> Mix Ratios /1--4. t Filter Pack type/size <br /> Installation Method Surge Block: - (y/n ) <br /> Quantity installed *- Discussed with-geologist: - (y/ n.) <br /> Type of method <br /> EH 29 2941 <br />