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MONITORING WELL INSTALLATION REP. r(-T <br /> ez O 03 CONSTRUCTION <br /> Dace: p C <br /> premise Address: �• GI �o� a Total Depth ) Q <br /> Screen Length (from) Cto) <br /> well Noe: U � Filter Pack (from) Cto) <br /> g Benronire (from) CLO) <br /> InsPector, Grout (from) Cto ) <br /> Drilling rig tyP <br /> Permit No. Auger O .D_ 1.D. <br /> n O I Completion - Stove pipe/christie box Ccircle one) <br /> Drilling Company. <br /> casiag <br /> Driller. S height <br /> Consultant ♦� <br /> Geologist AWVE-GRCUND \ r <br /> CCMFLTICN COMP <br /> =ICN <br /> CQMPt='T,CN <br /> SPECIAL PERMIT INFO. �� Ground Stzf� no <br /> Rn� <br /> Distance to sewer line <br /> Domestic well on site - ( y / n ) <br /> If yes, location and distance <br /> 5M 73 <br /> dotted <br /> SAMPLING /� z ween <br /> Holding Temperature �1V I pack <br /> Method C L� <br /> Screening Method <br /> Tracking Sheet - ( y / n ) <br /> Z� s L ;� • = t n. <br /> SPOILS l6 41 <br /> Storage Method 2 S MATERIALS/DEVELOPMENT � + <br /> Contamination Noted - ( y / n ) i �b� <br /> Storage Location I{ b S �I Casing <br /> type <br /> � ( SZ) �tBlank fL Screea <br /> G ,- 4 � �S Slot size <br /> GROUTING LNN40. �' " C � (5 � NCBags cement <br /> 3 I Buckets bentonite <br /> tf <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Metho Surge Block: - C y / n ) <br /> Installation Discussed with geologist - C y / n <br /> QuandtInstalled ) <br /> Type of medzod <br /> EH 29 29 <br />