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1 <br /> •ONITORING WELL INSTALLATION REPO• <br /> I �- lDate: /" �� L�A�7� e� CONSTRUCTION 0 <br /> �lZs S Total Depth <br /> Premise Address: Screen Length (from) (to) <br /> LAI <br /> Filter Pack (from) (to) <br /> Well No.: ! Bentonite (from) (to) <br /> (� Grout (from) 2 (to) <br /> Inspector: Drilling rig �? <br /> ��J � Auger O.D. �f I.D.�— <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: � T4 L height <br /> Consultant <br /> Geologist " - -µA_ ABOVE-GROUND �i CHR -y.gpX <br /> COMPLETION 1� CCMPLETICN <br /> rd Surf <br /> SPECIAL PERMIT INFO. bU <br /> ��� proal <br /> � SD/ <br /> Distance to sewer line 72.8 n <br /> Domestic well on site - ( y <br /> If yes, location and distance - .5 ft. <br /> = m <br /> _ c <br /> doff" <br /> SAMPLING sac9cn <br /> P <br /> Holding Temperature =_ <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) 5 - n <br /> n. <br /> 0 <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) Casinge 'r`( �' 46 <br /> Storage Location_ Blank ft. Screen da 1t• <br /> Slot size Ol�I <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Filter Pack type/s' l? <br /> Mix Ratios <br /> Installation Method Surge Block: - (yn ) <br /> Discussed with geologist: - (y/ n <br /> Quantity Installed ) <br /> Type of method <br /> EH 29 29 <br /> /0�z ��� � � <br />