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MONTTORING WELL INSTALLATION REPOF�L" <br /> Date CONSTRUCTION - <br /> Premise Address: !4 Total Depth- .--•--- <br /> r p / Screen Length (from) ([o) <br /> filter Pack (from) <br /> en[onite ( (to) 7' <br /> Wel! No.., ✓''�� from). 7 —(to) S <br /> „ rout (from) S— r to) <br /> Inspector: /F "�' Drilling rig type_ <br /> Perini[No. � �p, <br /> r Auger O.D. I.D. <br /> `"�Y s� Completion - Stove pipe/chnstie box (circle one) <br /> Drilling Company: � <br /> rw <br /> � 1�u� <br /> casing <br /> S� hg <br /> ( <br /> Consultant G✓ 20 <br /> a51 _ EGeologist ASQV -GROUND <br /> COWLETCN <br /> r apX <br /> SPECIAL PERMIT INFO. wvf ' " Grcurd Sulaer <br /> Distance to sewer line <br /> Domestic well on site - { y <br /> If yes, location and distance - �- <br /> _ ft. <br /> SAMPLING <br /> so-clen _ <br /> Holding Temperature— r gave P.-<X <br /> Method <br /> Screening Method <br /> Tracking Shcet - y/ n) <br /> SPOILS e - <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n } rr <br /> Storage Location Casing type <br /> Blank ft. Screen! / fr• <br /> Slot size c9 <br /> GROUTING Bags cement <br /> 1 Buckets bentonite <br /> Depth to water r $ Bags sand/gravel &AtL_-- <br /> Mix Ratios Filter Pack type/ ' e <br /> Installation Method Surge Block: - ( n ) <br /> Quantity Installed ^J S Discussed with geologist: - (i <br />