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if <br /> I' MONITORING WELL INSTALLATION REP. KT <br /> I <br /> Dale: p 1 CONSTRUCTION ! r� <br /> Premise Address : / L C Y/6n" Total Depth , V <br /> "� '1 54S-creek� Screen Length (from) Cto)U — 5 2 Filter Pack <br /> Well No- : S , ,[\y 1+1 Benronite (from) Cto) <br /> Inspector: 0 N B Grout (from) Cto) <br /> Drilling rig type <br /> Perini[ No. Auger ODI I-D • <br /> Com tenon - Stove pipe/christie box (circle one) <br /> Drilling Company: (RIp <br /> n <br /> Driller- 8 �/Q � y casing <br /> Consultant � height <br /> ri sio re lbt _ <br /> [ 1� - \ <br /> Geologic _ �� <br /> n AA�bP��TANO d-AIS -oOX <br /> COMP_ 1 ICN <br /> SPECIAL PERMIT INFO - <br /> Gy nd Strfa --� <br /> gtcc.2 <br /> Distance to sewer line <br /> Dcmecrir: well on site - ( y / n )If yes, location and distance - f0 CtST It <br /> I $ OT <br /> to CLST _ 3 <br /> ?S Cl ST Z <br /> 3o CL5T (14 J+) 51 `f = a <br /> SAMPLING 35 SL u , y domed <br /> (� q() ( ItwaS 115 an <br /> Holding Temperature_ <br /> Method.. Sd S" <br /> Screening Method_ _ <br /> Tracking Sheet - ( y / n ) <br /> SPOILS C (�S <br /> 5 <br /> Storage Method_ Ie WSJ <br /> 0 MATER /FDE'VELOPMENT <br /> Contamination Noted - ( y / n ) IS CLST <br /> Storage Location_ 2U C �t Casing type <br /> S1 6 Blank fr- Screen EL <br /> 2J t(/S1 Slot size <br /> GROLMNG � 30 Bags cement_ <br /> (tol3' [�/ � . q Buckets bentoni[e <br /> Depth to water 0 f t t 15 Bags sand/gravel.. <br /> Mix Ratios <br /> 9 ` 4� ) Filter Pack typesize <br /> CLW/ 0 Surge Block: - ( y / n ) <br /> Installation Method <br /> Discussed with geologist - ( y <br /> Quantity Installed. 0 Okj <br /> s 3 Type of method <br /> I <br /> EH 29 29 S ' /L <br /> cL 111 <br /> Oder <br />