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...ONITORING WELL INSTALLATION REPO. <br /> Date: / % CONSTRUCTION <br /> Premise Address: % � �� t Total Depth <br /> „ Screen Length (from) (to) <br /> Well No.: �� �' i -P71 �—r� Filter Pack (from) a:,;k, (to)q'• " <br /> Bentonite (from) Ll' --7 (to)'L t- <br /> Inspector: � n^�`'e� Grout (fro ) a' N,`' (to) A <br /> Drilling rig type M S <br /> Permit No. S(� �� __ Auger O.D. G k I.D. •a <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant A, .&&1,1 � —q <br /> Geologist??,`e- T <br /> Ai80 -GROUND CHRM Y-80X <br /> CONFLETION CCMPL-=nCN <br /> SPECIAL PERMIT INFO. G=rd 5+rfact <br /> Distance to sewer lined% Grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> .��.ft. ft. <br /> SAMPLING 410rad <br /> C • sadcn <br /> 8 <br /> Holding T mperature PICS <br /> gf1Yw(SdCSC <br /> Method-- t�{ — <br /> Screeni g Metho f-'-rfn _= <br /> Tracking Sheetl'(y� n ) <br /> 2 Z fL <br /> SPOILS L n . <br /> Storage Method Vi'-Gl�'L� MATERIALS/DEVELOPMENT_ <br /> Contamination Noted - y n ) r I, <br /> Storage Location _ Casing type I/ P U-� <br /> Blank _ft. Screen <br /> Slotsize <br /> GROUTING Bags cement L <br /> Buckets bentonite <br /> Depth to water t�� �� Bags sand/gravel <br /> Mix Ratios t ti ",At Filter Pack type/size S/Z <br /> Installation Method Surge Block: - ( y n <br /> Quantity Installed <-f Discussed with geologist: - / n ) <br /> Type of method Icy <br /> EH 29 29 <br />