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MONITORING WELL INSTALLATION REP-4T <br /> Zoa f� 17 2� <br /> CON 5T'RiJC-170N <br /> Date: /Zo <br /> k'nl y Total Depth <br /> Pzamise Address: Screen Length (from) :a,,—(to) 77 <br /> M Filter Pack (from) (to) `} <br /> Well No.: Bentonite (from) <br /> W Grout (from) <br /> Inspector. Ding rig type <br /> L2 Auger O.D. ` I.D. <br /> Permit No. s Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> (✓ �1 t �5' casing <br /> Driller. height <br /> � 77 <br /> Consultant 'K y�'' W, ,VT <br /> _ <br /> Geologist ABOVE-GROUND <br /> CrNP!R nN CPL=-L iCN <br /> SPECIAL PERM INFO. � G=rld SLrf.� <br /> i <br /> lout <br /> Distance to sewer line P10 <br /> Domestic well on site - E Y <br /> If yes, location and distance - to <br /> v—>6aDr _ -tod <br /> e <br /> SAMPLINGwc+cn <br /> Holding Temperature (7 _ pack_ <br /> Method _ <br /> Screening Method a <br /> Sheet - E Y/ nQ IL) R 7 _ <br /> Tracking �.J <br /> SPOILS 6 14a Su�Q <br /> NIATERIAI.S/D EVELOPMENT <br /> Storage Method �S <br /> Contamination Noted - (y Casing type <br /> Storage Location Blank -� fr„ Screen <br /> Ra� C Slot size <br /> GRGR UTING Bags cement <br /> ���' Buckets bentonite <br /> 2 b4 o Bags sand/gravel <br /> Depth to water Filter Pack type/ e <br /> Mix Ratios �6 a Surge Block: - E y/ n ) <br /> [nstalladon Method Discussed with iogist - Oy n) <br /> Quantity Installed 1Type of method <br /> EH 29 29 1 <br />