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MONITORING WELL INSTALLATION�REPOxf <br /> Date:_ In- -7-6W CONSTRUCTION r _ <br /> Premise Address: <br /> `ri'GG�y�/Z. a Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to). /lG <br /> Y�. Bentonite (from) ZG (to) /?•u <br /> Inspector: Grout« - (from) <br /> (to) O <br /> +� Drilling rig type <br /> Permit No. . �Ji/.__ Auger,O.D. I ` I- I.D. <br /> Drilling Company: , Completion --Stove pipe/chnstie box (circle one) <br />' /v"CJ <br /> Driller: t casing _ <br /> height <br /> Consultant <br /> Jel <br /> Geologist ._ <br /> r ABOVE-GROUND <br /> COWLETON CHRMTY-BOX <br /> OMPLEnON <br /> SPECIAL PERMIT INFO. GroundS�iaa$ <br /> Distance to sewer line ,arm <br /> Domestic well on site - (y n <br /> If yes, location and distance - <br /> !Z!o tL <br /> a <br /> SAMPLING = o' ' <br /> alattad c <br /> Holding m �Ct� - O sacron $ K <br /> Te peratureM <br /> Method �rsyst Pack <br /> Screening Method <br /> Tracking Sheet - n ) <br /> « tL <br /> SPOILS <br /> Storage Method f Ll.:c�c-c 1'� F l f " MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y gn � _ ° ype- <br /> a Location t n x- <br /> g G Casing ta ..4 <br /> Stora ��� <br /> Blank : ft. Screen ft. <br /> Slot size O Z-0 <br /> GROUTING Bags cement 71� <br /> �✓ Buckets bentonite <br /> Depth to water `�� Bags sand/gravel <br /> - Mix Ratios ZIE 5 r ,Filter Pack type/size <br /> Installation Method Surge Block: - (y n µ. <br /> Quantity Installed <br /> Discussed with ge`or�glst: - (Vy n ) <br /> —Type of method <br /> EH 29 29 <br />