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MONITORING WELL INSTALLATION REPO <br /> Date:_ / CONSTRUCTION <br /> Premise Address: �� Lv, .�-t - Total Depth d <br /> »�-- Screen Length (from) (to) <br /> Well No.: ��" Z, 3 y Filter Pack (from) 39 (to) �! <br /> Bentonite (from) -L (to) <br /> Inspector: 1E/1��t h�fi _ ' Y Grout (fro _(to <br /> Drilling rig type <br /> Permit Auger O.D. :I.D. " <br /> / hh Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company:/✓Or��Ga/ JJ � _ 1 <br /> DrillerFi-`-z f casing ` <br /> ». >. height <br /> Consultant �-e0—�� i ` <br /> Geologist04� Z2L <br /> s k - <br /> . ABOVE-GROUND COIF M-SOX <br /> OOMPLETION <br /> �. COMPLETION <br /> SPECIAL PERMIT INFO. Gmund Sriacs <br /> Distance to server line ''� <br /> Domestic well on site - y n) i ft. <br /> If yes, location and distancetL <br /> &aft. I <br /> SAMPLING <br /> d� sacicn <br /> Holding Te erature L <br /> Pack <br /> Method i1&— �� <br /> Screening Method •, ; <br /> Tracking Sheety n ) Lz�� <br /> ft. II ,& ' ft. <br /> SPOILS M, 4 �l <br /> f� H <br /> Storage Method �f° MATERIALS&EVE_LOPMENT <br /> Contamination Noted . y n ) t ,, <br /> Storage Location6Casing type <br /> Blank ft. Screen <br /> ! Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite',_ <br /> Depth to water Bags Bags sand/gravel 5 <br /> Mix Ratios C S Filter Pack type/ e 3 <br /> Installation Metho Surge Block: - y n ) <br /> Quantity Installed .. Discussed wit eologist: -/[.v,/' n ) <br /> Type of method [. <br /> EH 29 29 <br /> 'S <br />