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MONITORING WELL INSTALLATION REPn*-� <br /> Date: CONSTRUCTION <br /> Premise Address: a J ��� Total Depth _ _" <br /> Screen Length (from '" (to) <br /> Well No.: M w _ IN�� Filter Pack (from (to) 62-• -4�'o <br /> Bentonite (from) 6� (to) <br /> Inspector: 'v`$'e Grout (from) (to)_ I lfl <br /> Drilling rig3 <br /> Permit No. T Auger O.D.,77`( C.D. ef <br /> Completion - Stove pipe/clu•isde box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> A height <br /> Consultant _. <br /> Geologist -- <br /> AEFC E.GRCUNO \ CHRM Y-SOX <br /> COMPl.I*TION COMPLETION <br /> SPECIAL PERMIT INFO. Ground 5�sfaea <br /> ^t.) Kai✓ <br /> Distance to sewer line <br /> Domestic well on site - (y SSI tt. <br /> If yes, Iocation and distan - / . <br /> IL�. <br /> y°> m <br /> R <br /> SAMPLING <br /> secicn N —_ <br /> Holding Tem erature g, P <br /> Method : <br /> Screening Method a — <br /> Tracking Sheet y n ) : — <br /> SPOILS <br /> Storage Method �� MATERIALS/DEVELOPMENT <br /> Contamination Notedsr/ r,p�� <br /> Storage Locations Casing type <br /> Blank ft. Screen ft. <br /> Slot size U -0 <br /> GROUTING Bags cement ;�_I <br /> / Buckets bentonite 55 <br /> Depth to water �7� `�� Bags sand/gravel *$ tv <br /> Mix Ratios Filter Pack type/size 3 <br /> Installation Method Surge Block: - ( NZ-10 <br /> Quantity Installed Discussed with geologist: - Gi/ n ) <br /> 43 Type of method <br /> EH 29 29 <br />