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MONITORING WELL INSTALLATION REP <br /> CONSTRUCTION <br /> Date: fie➢ `, <br /> Premise Address: 00 B*L w - W - A&'V1J+j � Total Depth <br /> =, .7 <br /> Screen Length (from) ([o) <br /> �✓, / �v C ) Filter Pack (from) (to) <br /> Well No.:-,z <br /> Bentonite (from) (to) <br /> r. 7 /"�""""`�� Grout (from) (to) <br /> Inspecto <br /> Drilling rig e <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/chrtstie box (circle one) <br /> Drilling Company Z <br /> casing <br /> Driller: � height 1 <br /> ri <br /> Consultant <br /> Geologist 0 "� ABOVEGROUNDygpX <br /> GOh�LEiION COMPLETION <br /> Ckwnd S�rfxs <br /> SP .IAL PERMIT INFO. <br /> ptcut <br /> Distan€e to sewer line <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - <br /> ^z __ m <br /> 0 <br /> o a <br /> SAMPLING S�N�1 �j� slorad <br /> socicn —_ <br /> g P �tJLA <br /> Temperature <br /> Method <br /> Screening Method _x = <br /> Tracking Sheet - (y/ n ) <br /> e <br /> SkN�i . fl. <br /> SPOILS <br /> Storage Method MATERIALS/DEVEPMENT <br /> Contamination Noted • (y/ n) Casing type r Uy , 6 <br /> Storage Location Blank Screen --h' <br /> slot size ------ <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Depth to water <br /> Bags sand/gravel_ <br /> b <br /> Filter Pack type/size ?- L' <br /> Mix Ratiosgorge Block: - ( y/tl ) N <br /> installation Method Discussed with geologist. - / n) <br /> Quantity Installed Type of method <br /> EH 29.29 <br />