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! MONITORING WELL INSTALLA717ION REPOn f <br /> Date: /D Uj2t� . .,.CONSTRUCTION <br /> Premise Address: lam/y Total Depth I3 � <br /> Screen Length (from) /3 _ (to)_ l2G_ <br /> Well No.: cly��l/�/ l� Filter Pack (from) /3'5 (to}_/?- <br /> "Bentonite - (from) l: (to) /-X <br /> Grout (from) /h (to) O <br /> .. Inspector: n �S <br /> p Drilling rig type <br /> Permit No. % �5 fAuger O.D. $ ! I.D. <br /> w ''Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Dler t casing <br /> ril <br /> c ^x <br /> - height - �- <br /> Consultant <br /> ; <br /> Geologist ,ABOVE-GROUND C#iRM Y-BOX ' <br /> COWLET$ON (; C <br /> i, <br /> SPECIAL PERMIT INFO. <br /> Ground Surface <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y � <br /> �. If yes, location and distance - <br /> " y •� ., 'tet � ,�� ;� -.� i.� ,s+�_ ,��.�'�t-+4`Sg. .� ��'� y � n t � � .. a. <br /> stoned <br /> _ � o-- -. _ � w.. ,.,,.,.�-.,r-+»s..,.dwr.r•l .�1' ,.._; �--r. :t,.m� ,w- . �+.t-.;'�- _ <br /> SAMPLINGs� rte" -K <br /> "� -swan "° L <br /> '>a <br /> Holding Temperature- � �Q rc . •.��-, �j��yy + �xvel pacfc <br /> Method r <br /> Screening Method ,'- •'; ,, _ Q !" j 4. <br /> Tracking Sheet' - {y/ n) � <br /> SPOILS ` <br /> l L��" t ' _ MATERIALS EPW <br /> NT <br /> Storage Method ,,,k ,� e <br /> ik Contamination Noted - y n �sr �} <br /> s Storage Location td 5 Casing type 7 <br /> OF *;,L . �'•"z.- '` `"' r Blank'' lz(o ft�• ScreenL, $ ft. <br /> a 3 "e* <br /> SIot size_ - OLo <br /> f GROUTING " Bags cement o"�y <br /> Buckets bentonite <br /> 5 r ` ,. '� y Bags s'and/gravel <br /> Depth to water . <br /> Mix.Ratios Z Filter Pack type/size <br /> Installation Method Surge:Block: (y n- :` N" <br /> Quantity Installed - - a Discussed with geologist ; (y n ) <br /> _ <br /> o <br /> Type f niethbd <br /> *. <br /> `,. <br /> EH 29 29` <br />