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MONITORING WELL INSTALLATION REPOnf <br /> Date: �Y r CONSTRUCTION <br /> Premise Address: r/6 7 �l R t"C Total Depth <br /> AW <br /> n Screen Length (from) Zt> (to) e 0 <br /> Well No.: c„ -%��"'� -"\ ' Filter Pack (from) 1.0 (to) <br /> ' * Bentonite (from) (to) <br /> Inspector: `~ ^s Grout (from) (to) 1 <br /> _,Drillmg rig type <br /> Permit No. - B 3 -� c " Auger O.D. w I.D." <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:'t <br /> Driller ��^^� ' - ,� casing,, <br /> i� - ,... `_�.° ..,-..`"4 .,, height '^ <br /> Consultant <br /> Geologist � •- ' <br /> ABOVE-GROUND .. 'CHRZTY_Sox <br /> CowLET1oN <br /> COMPLEX <br /> SPECIAL PERMIT INFO ` { Ground SuAa" grout <br /> Distance to sewer line <br /> Domestic well on site'- (y Q 1_j1.k " T" <br /> If yes, location and distance N ti : rte, <br /> ,,- ,-t•• <br /> . •.. , 4�.,, *�� �. . . .•..; ,,, e. s• ,ate, — <br /> e _ m <br /> SAMPLING . *.` 1 i 3 x slotted _ S <br /> on = <br /> Holding'Teinperature -vat Pack <br /> Method = <br /> Screening Method <br /> Tracking Sheet _ (.y/ n•) <br /> _Te ti amu» ta`x :3 , r 5 S a tt. = fL <br /> SPOILS <br /> Storage Method Ys MATERIALS/DEVELOPMENT <br /> �� Srr'-f" d� <br /> Contamination Noted - n 3� s ��`tt �^ _ , `%" �,t �J �."''"(� A_ <br /> Storage Location � � ✓p Casing type r �e d �lT� <br /> Blank /O ft. Screen—ft. <br /> Slot size O?D <br /> GROUTING , Bags cement <br /> Buckets bentonite <br /> Depth to water 3 '' ti : "; Bags sand/gravel r <br /> Mix Ratios S C' fi Filter Pack type/size <br /> Installation Metho 4dt� ��Z' Surge Block: - (y n <br /> •, Quantity Installed -� Discussed with geo ogist: • (y n 7 <br /> Type.of method �- <br /> ...a, , EH 29 29 <br />