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MONITORING WELL INSTALLATION REP# <br /> Date: -05 •C( . V CONSTRUCTION <br /> Premise Address: q?.e)''b 05 l V44 Total Depth /6•+6 <br /> Screen Length (from) (to) <br /> Well No.: (16 Filter (from) <br /> Bentonite (to) <br /> Inspector: - 1717t41� Grout (from) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion to <br /> pipe/christie box {circle one) <br /> Consultant F�701�L �JVVI/ZOA/H(3TA7'Y(.., cj(�„,o <br /> Geologist r-r-Qnl /Z1,W <br /> J <br /> SPECIAL PERMIT INFO. /ABOVE-GROUND <br /> COMPLETION LM-BOX <br /> Distance to sewer line L7 COMPLETION <br /> Domestic well on site - y n ) nd S` °o� <br /> If yes, location and distance - orout <br /> ?I�if G✓rX1t9t i 5 6YLLvI GAS(f!) 70 Gut S I-F- <br /> Tbkr 7GVLt�S l�GaruJ-ia/l� � tY-t"Z�• �'�St�AJcC. . ft. <br /> n. <br /> SAMPLING �, 6'�•s –� .S/ l 6 b 'Iv 0<-/(,,S — • <br /> Holding Temperature do <br /> Method G on <br /> Screening Method <br /> Tracking Sheet - n) <br /> SPOILS <br /> Storage Method ti TERIALS EVELOPMENT <br /> Contamination Notes - y n ) <br /> Storage Location SFILr Casing e <br /> Blank ft. Scr n fr. <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/grave <br /> Depth to water g Filter Pack size <br /> Mix Ratios_/�� l� Ce7VIUVI –X4K Z/L!� Surge Bloc . - (y/n ) <br /> Installation Method rt FYL Discuss with geologist: - (y/ n ) <br /> Quantity Installed Typ of method <br />