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�YONITORING WELL.INSTALLATION REPOnf - <br /> Date: CONSTRUCTION - <br /> Premise Address:' /3�a / 12 Total Depth 2 7r <br /> .,Screen Length (from) (to) ZS <br /> Well No.: Mme/'S Filter Pack (from) (to) LS <br /> Bentonite -(from) l'z(to) 3 <br /> Inspector: _ .. Grout _(from) <br /> Drilling rig type <br /> Permit No. - <br /> ~~� . - Auger O.D. ` I.D. <br /> R Completion- Stove pipe/christie box .(circle one), <br /> Drilling Company: G Y <br /> .Driller: � �' casing . <br /> - height <br /> Consultant <br /> Geologist w <br /> ABOVE-GROUND - <br /> G�OMPLETION CHRM Y43OX <br /> SPECIAL PERMIT INFO. Ground S COMPL E Tl0 <br /> Distance to sewer line Nv _ l�{ - proof <br /> Domestic well on site - y n ) AZ <br /> If yes, location and distance - � <br /> a• p <br /> SAMPLING ., - .- _ . sfottad — # <br /> Holding Ternperapre <br /> Method <br /> Screening Method <br /> Tracking Sheet 1y ) <br /> ft. ft. <br /> SPOILS x <br /> r . <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - <br /> Storage Location O'k%'d' Casing type___2 3cXc 40 - <br /> Blank S ft. Screen ft. <br /> V a Slot size <br /> GROUTING _ Bags cement < . <br /> ' Buckets bentonite <br /> Depth to water N,61 . .}S� �. _ 'pags-sand/gravel �,e�� y>. <br /> Mix Ratios ti* -Filter Pack'type/size Z � - <br /> Installation Method' , Surge Block: - (y n <br /> Quantity Installed- ?" °•. -- - - =_ Discussed_with ge, ogist (.y/n ) <br /> Type of method <br /> EH 29 29 k? `°* -a '" s .`,;,�-ti. •, r� r " <br />