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MONITORING WELL INSTALLATION REPO <br /> Date: (�� CONSTRUCTION <br /> Premise Address: Total Depth �d <br /> Screen Length (from) 33 (to) y <br /> Well No,: (V�W Filter Pack (from) (to) <br /> Bentonite (from) a (to)471 <br /> Inspector: _ LA��4tt ���'cZ Grout (from) (to) <br /> Drilling rig type L-ha a S a9,D/1 <br /> Permit No, d 1p-2 Auger O.D._II I <br /> Drilling Com <br /> pany: <br /> U--1Aj Completion - Stove pip stie b (circle one) <br /> Driller: i'A#✓ � casing <br /> -- - height <br /> n <br /> Consultant f V <br /> 7/41 <br /> Geologist Y <br /> ABOVE-GROUND CHRZTY-80x <br /> CONFLETION coWUTICN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line 4r 161 <br /> I <br /> Domestic well on site - (y ) <br /> ' ft, <br /> If yes, location and distanc - ft. <br /> v a <br /> SAMPLING slored r — G <br /> 4aC7Cf1 x•' <br /> —_ <br /> Holding Temperaturevol <br /> <' <br /> Method ".. _ F <br /> ack <br /> Screening Method M10 _ <br /> Tracking Sheet - (y/ n ) ' <br /> LO <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/®) /i P U c <br /> Storage Location 0:— Casing type <br /> Blank 33 ft. Screen ft. <br /> Slot size . O 1 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size l y - <br /> Installation Method Surge Block: - (y/11 ) T <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />