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t AgITORING WELL INSTALLATION REPOR' - <br /> Date: ��7 CONSTRUCTION l <br /> Premise Address: l_ Total Depth <br /> Screen Length (from) (to) .� <br /> Well No.: � �� Filter Pack (from) � ` (to) `�Z <br /> / Bentonite (from) 47-' (to) D <br /> Inspector. �C/�� Grout (from) 4e5 (to) —5-nsrx- <br /> Drilling rig type 5 - <br /> Permit No. Auger O.D. I.D. `/ <br /> Completion- Stove pip stie box ircle one) <br /> Drilling Company: <br /> Driller., L6casing <br /> height <br /> Consultant WT_ <br /> Geologist ��,/,^/ i�'/9�'�'1 P,✓ ABOVE,GACUNO CHRI Y-30X <br /> fiTf <br /> COWLON COMPL-wnCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Wout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) 6 <br /> If yes, location and distance - & <br /> r. • <br /> SAMPLING •bro.� <br /> — <br /> Holding Temperature r <br /> =�, pack <br /> Method lAA41 <br /> Screening Method <br /> Tracking Sheet y n) <br /> SPOILS <br /> Storage Method PXfilk 1(5a '0 MATERTALS/DEVELOPMENT <br /> Contamination Noted - (y � �� <br /> Storage Location g type <br /> Blank ai ft. Screen 2 O ft. <br /> �Sloc size <br /> TI <br /> GROUNG ags cement �`r-�rLf7;Z-L124 <br /> / uckets bentonite <br /> Depth to coater J Bags sand/gravel -# o. . <br /> Mix Ratios ✓t'i w d7i Filter Pack type/siWo . <br /> Installation Me o �� (� Surge Block: - (y <br /> Quantity Installed Discussed with ge (y n3 <br /> Type of method <br /> EH 29 29 �64'� CeWC 4J <br /> / <br />