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NITORING WELL INSTALLATION REPO <br /> Date: C Q CONSTRUCTION <br /> Premise Address: d 0 -[ Total Depth-1 <br /> Screen Length (from) I (to)__ <br /> Well N �^ ! Filter Pack (from) r (to) <br /> Bentonite (from) •, (to) 3,o <br /> Inspector: Grout (from) a (to) <br /> Drilling rig type UU <br /> Permit No. d d 2S� Auger O.D. I.D. ! <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: cas lnq <br /> I � � height <br /> Consultant <br /> Geologist <br /> f AEFO E-GRCltNO CHitM4OX <br /> COMPLETION COMPLETICN <br /> SPECIAL PERMIT INFO. GM=Urd SWa <br /> - grcvt <br /> Distance to sewer line <br /> Domestic well on site - {y/ n) <br /> If yes, Iocation and distance - / S tL <br /> ` SAMPLING ��r 5 (f:G b T��` o stored <br /> l� 1 socicn <br /> a x�. <br /> Holding T perature _ <br /> r <br /> Method _ P <br /> ack <br /> Screening Method <br /> Tracking Sheet / n) <br /> ire <br />{ SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT j <br /> Contamination Noted - n) V G <br /> Storage Location Casing type <br /> BIank (OS ft. Screen <br /> Slot size • 0 Z D <br /> GROUTING Bags cement I <br /> t <br /> Buckets bentonite <br /> Depth to water O Bags sand/gravel o <br /> Mix Ratios Filter Pack type/si21. <br /> Installation Method Surge Block. = (y Quantity InstalledDiscussed with ge - 0/ n } <br /> Type of method 76, <br /> EH 29 29 .. <br /> s <br />