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kIIITORING WELL INSTALLATION REPt � r_ <br /> Date: ^7i�1 ' 2S ' - T CONSTRUCTION <br /> E Premise Address: '2:Z-)Oz) qN Total Depth Z <br /> i - 4 Screen Length (from) _ 4 0 (to) Z� <br /> Well No.: 1 '3 Filter Pack (from) `7 (to) <br /> �- Bentonite (from) <br /> Inspector• Grout (from) (to) � <br /> n - - Drilling rig type - <br /> Permit No. D b Auger O.D. I.D. <br /> �- — Completion - Stove pipe/christie box (circle one) 4 <br /> Drilling Company: <br /> Driller:_ casing <br /> height I <br /> Consultant J D llll <br /> Geologist r <br /> ABOVE-GROUND. CiiiSTY-BOX <br /> - <br /> COMPLETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Grourd Surface <br /> Distance to sewer line VIA grout <br /> Domestic well on site - y n ) S IL <br /> If yes, location and distance - <br /> V <br /> tL <br /> LCA n. <br /> ``y, , I <br /> q <br /> SAMPLING ¢ <br /> O slonaa <br /> soon <br /> Holding Temperature <br /> Method — gr"'iW pa <br /> Screening Method <br /> Tracking Sheet a y n ) _� <br /> fL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT . <br /> Contamination Noted - (y it <br /> Storage Location r �' -- Casing type <br /> Blank ft. Screen ft. <br /> Slot size. [L C�7i4 <br /> GROUTING Bags cement --- - <br /> / - Bucked�bentonite <br /> Depth to water Bags an <br /> Mix Ratios Filter ack type/s'ze <br /> Installation Method Surge Block: - /n } <br /> 1 <br /> Quantity Installed Discussed with geolost: - n) , <br /> Type of method_ 91L61 <br /> EH 29 29 <br />