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MONITORING WELL INSTALLATION REP. rLT <br /> e <br /> Date: 5� , CONSTRUCTION <br /> Premise Address: � � Total Depth <br /> \\ `� Screen Length (from) (to) � <br /> Well No.: Uv �. Filter Pack (from) f g (to) _ <br /> Benronite (from) (to) / R <br /> Inspector Grout (from) (to) <br /> .S�d2wgt �, Drilling rig type <br /> ger O.D. LD. <br /> Permit No. o Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller. heLght <br /> Consultant7W <br /> _ <br /> Geologist �rn � ( n �VS�GRCUNO <br /> COMPLE71OX <br /> pJ�u."p�,D,, � SMP!�CSON COAAPL� �CN <br /> SPECIAL PERMIT INFO. v / Gm""d S�� T-- <br /> f <br /> gfart <br /> Distance to sewer line <br /> Domestic well on site - ( y / n ) Y <br /> If yes, location and distance - p CIE k <br /> / Z <br /> IS d o > <br /> SAMPLING domed = j <br /> I ZO s sm�9 fCn71"1 pack <br /> Holding Temperature �or <br /> Method ` <br /> Screening Method LJ _ <br /> Tracking Sheet - ( y / n ) <br /> SL <br /> / N L ♦ - fz <br /> D <br /> SPOILS 3S <br /> StorageMethod /C MATERIALS/DEVELOPMENT <br /> Contamination Noted ( y n ) C�asing type ----- <br /> Storage Location Blank fr. Screen <br /> Slot size U` 10 <br /> J — <br /> GROU ITNG Bags cement <br /> Buckets bentonite <br /> Depth to water, k)(2 Bags sand/gravel <br /> Mix Ratios L Filter Pack typesize <br /> d 'l Surge Block. - C y / n <br /> Installation Metho ) <br /> ( �l�l Discussed with geologist n <br /> - C y / <br /> Quantity Installed ) <br /> 6 Type of meth <br /> EH 29 29 v <br /> sLeV� s <br /> � <br /> 4 �� <br />