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MONITORING WELL INSTALLATION REP ORT <br /> Date:_ �' i D�' CONSTRUCTION <br /> Premise Address: fL60 Total Depth <br /> Screen Length (from) (to)�_ <br /> Well No.: blJ �� Filter Pack (from) (to) S <br /> f Bentonite (from)_-___ G t ^_(to) <br /> Inspector. , 4Jt CG` Grout (from)-- <br /> t Drilling rig type <br /> Permit No. �'l b�_ -_ Auger O.D. I.D. <br /> Completion - Stove pipe/cluistle box (circle one) <br /> Drilling Company:____, <br /> Driller:_- - casing <br /> height <br /> Consultant C—, 17 <br /> Geologist elnkcx, N Iv.�+� ._ <br /> A 0 YE-G B CUM D C� S7Y 30X <br /> CQ ti r'LETbN C-OtAPL'nON <br /> SPECIAL PERMIT INFO. sulact <br /> Distance to sewer line QfO` <br /> Domestic well on site .- ( <br /> If yes, location and ante - tt. <br /> S' h. <br /> v' a <br /> C <br /> 0 <br /> S AMP LI NG <br /> s¢cicn <br /> Holding Ternperatur <br /> Method <br /> Screening od <br /> Trackin beet - (y/ n <br /> ._ n. V 5- ' . <br /> SPOILS <br /> Storage Method MATERIALS[DEVELOPMENT <br /> Contamination Noted - { ' /n} r <br /> Storage Location—en,- •s r Casing type Z `– ft <br /> Blank___b 9– fc. Screen o� D <br /> Slot size dzo <br /> GROLMNG Bags cement <br /> Buckets bentonite <br /> Depth to water I JO 4-- �� Bags sand/gravel <br /> MiX Ratios Filter Pack type/size <br /> ,installation Method Surge Block: - (y/n ) <br /> Quantity Installed Discussed vrith geologist: - (y/ n ) <br /> Type of r:�ctliod <br /> EH 29 29- . <br />