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Y <br /> OONITORING WELL INSTALLATION REP* <br /> Date: Zvrr of CONSTRUCTION <br /> Premise Address: �6`�-�'— /` ^� V92 � Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Lr 9 5a 4% 43 jO t Filter Pack (from) <br /> (to <br /> Bentonite (from) (to) ?,S <br /> Inspector: Grout (fro ,` (to)4 l <br /> O /Q� Drilling rig type <br /> Permit No. <br /> 2 5/ Auger C.D. LD. <br /> Com le ' - Stove pipe/christie box Circle one) <br /> Drilling Company/: <br /> cas. g <br /> hei9h <br /> Consultant ♦� •z- <br /> Geologist ABOVE-GROUND CHRIS'N43OX T <br /> COWPLETION COMPLETION <br /> SPECIAL PERMIT INFO. � Su tx� +---• <br /> /Ktaii /At 74 AW*2 S,J�p f D grout <br /> r 7 <br /> Distance to sewer line $�ili`t` ZS <br /> Domestic well on site - (y/ n ) n <br /> If yes, location and distance - n• <br /> o <br /> o <br /> SAMPLING {loodsac5on =_ <br /> Holding Temperature V"v°t Pack <br /> Method <br /> Screening Method = y' <br /> Tracking Sheet - (y/ n) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type LrY S` <br /> Storage Location Blank 30 ft, Screen fJ fr• <br /> y�lot size <br /> GROUTING LL! Bags cement Itil <br /> 1( Buckets bentonite n <br /> 3S Bags sand/gravel �� �' <br /> Depth to water Filter Pack type/size 71 <br /> Mix Ratios f� <br /> Installation Method � ��` f Surge Block: - �n) <br /> Quantity Installed = `� Discussed with geo ogist: - y n <br /> Type of method -4bQ� <br /> EH 29 29 <br /> b <br /> LAi 9f 3r <br />