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MONITORING WELL INSTALLATION REPORT <br /> Date: <br /> F+ Cw'rlSt' � , oZ�DS CONSI�RUCT(ON <br /> 4�S LQ r�17 2c Total Dcpth •20 �t?.k <br /> Premise Address: Screen Length (from) e20 (to) 5 ' <br /> Filter Pack (from) 2 Q r (to) <br /> Well No.: Bentonite (from) y.S' (to) S ' <br /> ^ r Grout (from) <br /> Inspector. V Drilling rig type <br /> loo 4 3 2 '7 Auger O.D. F , _djn. _ I.D. <br /> Permit No. Completion - Stove pipe/duistie box (circle one) <br /> Drilling Company: W Y ti i n-NC <br /> casing <br /> Driller: /eI Y height <br /> JSr1 t4�+ ' - 1 Ort 4z - .� <br /> Consultant 6 E A c' &7YBO�4/yZ m i'n ABOVE�RCUND Geologist ocd� cxowLETfON <br /> SPECIAL PERMIT INFO. 9x2 <br /> Distance to sewer line 3'S ft. <br /> Domestic welt on site - (y n g• <br /> If yes, location and distance _ - _ <br /> PPS _ <br /> �9rniYw/T� L/Ip/+�sc f • /S ' 3. (. �rn- zlorai <br /> SAMPLING saccn = <br /> -a oC� e2°1 0 <br /> Holding Temperature m� •a PID <br /> Method <br /> Method �a', r484P�� _ .. <br /> Screening 2?I <br /> Tracking Sheet - )y n) o, �a-7 <br /> STS L46s <br /> SP01LS in �7Mt�b2//e ,C/1 <br /> Storage Method - �/ <br /> r MATERIALS/DEVELOPMENT <br /> Contamination Noted - / ) + Casing type 4 U 01191 D ft <br /> Storage Location ` — Blank ft Screen S <br /> Slot size <br /> . . muJ..11- Arl7vuditi WtrS a ' �U• Bags cement • <br /> GROUTING LLgPlf Buckets ben[oni[e �y of 9 e� r&, <br /> M W•Zp LusZ <br /> gm�jEags sandlgravcl L <br /> Depth to water 4a�� . Facer Pack type/size <br /> Mix Rados imeld(- Surge Block: - C Y n <br /> dttstalladon Method 9 J f� Discussed vAth geologist: - (y/0) <br /> Quantiryinstallcd � Z ty Type of Method <br /> �tr r <br /> EH 29 29 " <br /> k !acts hod �rt��rtf �tr �} ll, � r6LJ)iL J o <br />