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' '..MONITORING WELL INSTALLATION REP( <br /> Date: <br /> Ai CONSTRUCTION <br /> Premise Address: 2Z1 Q� i-� � _ ' Total Depth_ � <br /> Screen Length (from) (to) <br /> Well No.: M(" �i _ Filter Pack (from)_ l e _(to) - <br /> Bentonite (from) Is Jto) <br /> Inspector: �.Ofl1r Grout {from) (to) <br /> Drilling rig type <br /> Permit No., ( X55 O Auger O.D. I.D. U <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company- <br /> Driller: 1J V cas Ing <br /> height <br /> Consultant <br /> Geologist W •` <br /> ABOVEGROUND I&CN <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Suiaca <br /> Distance to sewer line grout <br /> Domestic well on site - y n} C • <br /> If yes, location and distance tot <br /> - <br /> , � <br /> IV <br /> = Q <br /> SAMPLING <br /> a soon <br /> Holding Temperature Cl = gm+, Pack e <br /> Method <br /> Screening Method Aws 16 15P <br /> Tracking Sheet n ) <br /> SPOILS 4b <br /> Storage Method 'bw MATERLUS/DEVELOPMENT <br /> Contamination Noted - {y + <br /> Storage Location Dk I/ <br /> N)I'Tt <br /> Casing type NG2 <br /> Blank s ft. Screen i _ ft. <br /> Slot size <br /> GROUTING �F'� Bags cement <br /> ! Bucke 'G tonite <br /> Depth to waterBags san gravel <br /> Mix Ratios Filter ck type/ ' e <br /> Installation Method Surge Block: - y n ) <br /> Quantity Installed Discussed with ologist: - Q y j' n) <br /> Type of method_. Ig r <br /> EH 29 29 �� <br />