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QONITORING WELL INSTALLATION REP <br /> Date: <br /> I�i-so) CONS— <br /> Premise Address: <br /> zs <br /> Wel] No.: Total Depth�fv Screen Length (from) <br /> Filter Pack (from) (to) <br /> Inspector: _ Lam. Bentonite r (to) <br /> (from) 2 (to)�� <br /> Grout z <br /> Permit No.—,� ��� Drillinri (from) <br /> g g type (to)= <br /> /p / <br /> Drilling Company: C.GCCr c > ' CompletioAuger O.D.n - Stove a I.D. <br /> pip / hristieboxbox (circle <br /> Driller: Al�l� y <br /> Consultant_ �/-A��+ casing <br /> height <br /> Geologist /Q <br /> 31fO <br /> ABOVEGROUND <br /> SPECIAL PERMIT INFO. COWPLETION C RWY-BOX <br /> �( Ground Surface PLEn <br /> Distance to sewer line * — <br /> Domestic well on site - (y n cr�n <br /> If yes, location and distanc 2-X2— ft. <br /> S ft. ft. <br /> — m <br /> SAMPLING = <br /> dotted = 'i- c <br /> Holding Temperature <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/n ) <br /> 5 ` y <br /> SPOILS <br /> Storage Method <br /> Contamination Noted - (y/n ) MATERIALS/DEVELOPMENT <br /> Storage Location L &-4v <br /> Casing typeI <br /> _ <br /> Blank /r Screen 20 fr, <br /> GROUTING Slot size <br /> Bags cement_ 172- <br /> Depth <br /> 2,Depth to water_ = /Z Buckets bentonite / <br /> Mix Ratios_ Q /� — - Bags sand/gravel 0 <br /> Installation Method �� Filter Pack type/size 3 <br /> Quantity Installed_ Surge Block: - (y n <br /> gay' Discussed with geologist: - (y Tn1� <br /> EH 29 29 Type of method ��JJ <br /> 125- 0P �u/ !0 <br />