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DOSL UrfAW — Ste <br /> MONITORING WELL INSTALLATION REPO <br /> v <br /> A <br /> Date: Mob CONSTRUCTION dX <br /> Premise Address: IUB "" h Total Depth <br /> W Screen Length (from) (to) <br /> Well No.: IJ�S Filter Pack (from) (to) <br /> Benronite (from) (to) <br /> Inspector. N�r^ Grout (from) (to) <br /> p / Drilling rig type <br /> Permit No. 00/ �(Y�gy Auger O.D. I.D. <br /> / Completion - Stove pipe/clhristie box (circle one) <br /> Drilling Company: ^ <br /> Driller: casing <br /> / height <br /> Consultant <br /> Geologist S <br /> ABCVE-GACUND C.48mTY-80X <br /> r COMPLETION CCMPLEnCN <br /> SPECIAL PERMIT INFO. l 3, Ground Sutacs <br /> Distance to sewer line rJo27 Grout <br /> Domestic well on site - (y/ n ) 1 ft. <br /> If yes, location and distance - ---------- <br /> t� ft. <br /> l'r0k4i ft _ <br /> SAMPLING <br /> tlono — <br /> �/� Ifi axicn <br /> Holding Temperature <br /> Method <br /> Screening Method rD — <br /> Tracking Sheet - (y/ n ) <br /> W. — <br /> ft. _ = IL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) /i <br /> Storage Location Casing type ��—� <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />