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; j <br /> !f <br /> MONITORING WELL INSTALLATION REP. eff <br /> CONSTRUCTION <br /> Dace: c III ' IJ ,,I t {,() <br /> ?remise Address: ✓ l l/)n K �QJ 1 SMC +TVS Total Depth t <br /> ' .V tt Screen Length (from) (La) 4 C7 <br /> - 10 Filter Pack (from) 12 Cto) FO <br /> Well No.: V <br /> Bentonite (from) / (to) I <br /> JGrout (from) Cto) <br /> Inspector: Drilling rig type <br /> Auger O .D. I D <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: fJC1CL\ A� r/+�_ <br /> 1 casing <br /> Driller. 1 r ' 11 pi _r he :ghc <br /> 1 a° • <br /> Consultant <br /> Geologist / 0 ASCVE-GACUND \ <br /> CHAIS^!3CX <br /> CC NPL ETiCN 00M LE71CN <br /> Gtwnd sulaca -r---� <br /> SPECIAL PERMIT INFO. <br /> � <br /> p� " 0 Zt0tlt <br /> Distance to sewer line <br /> Domestic well on site - C y / n ) Cay v1 { <br /> If yes , location and distance - <br /> 73 <br /> i �bttnd � a <br /> SAMPLING on <br /> Holding Temperature = Tifoitack <br /> Method It o I = <br /> Screening Method74 <br /> Tracking Sheet • ( y / n ) tL _ I tt. <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method T? L <br /> Contamination Noted - ( y / n ) Casing type <br /> Storage Location Blank ft_ Screen fL <br /> Slot size <br /> Bags cement: <br /> GROUTING I <br /> Buckets bentonite <br /> 2Bags sand/gravel <br /> Depth to water. Filter Pack type/size <br /> Mix Ratios Surge Block: - C y / n ) <br /> Installation Method Discussed with geologist: - C y / n ) <br /> Quantity Installed Type of method <br /> EH 29 29 I^ J ,,� / <br />