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.ONITORING WELL INSTALLATION REP( <br /> Date: / ZS Z CONSTRUCTION <br /> Premise Address:l/IaT� Total Depth S2- <br /> n , Screen Length (from) '1 (to) ems`/ <br /> Well No.: W 2-C/ Filter Pac . (from) (to) G, <br /> en o kA j. (from) &5' _(to) <br /> Inspector: � � Grout (from) (-� (to) t) <br /> �, Drilling rig type, � 'IA�� Poi e <br /> Permit No. 1�' ,.302 Auger O.D. R' g I.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company:l�� <br /> Driller./1"(6 casing <br /> height <br /> Consultant d�/f� / '4 <br /> n <br /> Geologist /6rn <br /> ABOVE-GRCUND CNAtS'ry-SOX <br /> CONFLETION COMPLEnON <br /> SPECIAL PERMIT INFO. Ground Sudwe <br /> Distance to sewer line 4.,r- grout <br /> Domestic well on site - (y/ n ) 7 l�I ft. <br /> If yes, location and distance - <br /> �L..ft. ft. <br /> SAMPLING slot. _ <br /> socicn _ <br /> Holding Temperature A-1A <br /> Method _ <br /> Screening Method <br /> Tracking Sheet - (y/ n ) —_ <br /> �.x <br /> ft. <br /> SPOILS <br /> Storage Method !Tr�AIAVJC MATERIALS/DEVELOPMENT <br /> Contamination Noted� (y/ �q <br /> Storage Location,,"'P �P ��"'^^�\ Casing type _ 1°✓��`/� <br /> Blank Screen %o ft. <br /> Slot size G 20 <br /> GROUTING Bags cement <br /> Buckets bentonite .A,/� A66 �lwohl <br /> Depth to water - U Bags sand/gravel 4bA(x <br /> Mix Ratios Filter Pack type/ <br /> Installation Method M- = Surge Block: - y./ n ) <br /> Quantity Installed Discussed with geologist: -CY)/ n) <br /> 0 � l3 �� Type of method <br /> EH 29 29 /013� / V <br />