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MONITORING WELL INSI'.AL.I-ATION REP-r4-2 1p1'C4r <br /> Date: �� U /� . CONSTRUCTION <br /> Premise Address: <br /> - *urai�Depov <br /> C(4 Screen Length (from) Cto) <br /> Well No.: °1Filter Pack (from) <br /> _ (to} <br /> Q ( � Bentonite (from) (to) <br /> inspector. /y Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cnxistie box (circle one) <br /> Drilling Company: ( n <br /> Driller. /O ✓ cas Lng <br /> height <br /> Consultant <br /> Geologist A3Ca VI—=-GRCUNO <br /> A N C}-FiIS !00 X <br /> SPECIAL PERMIT INFO. <br /> Distance to sewer line <br /> Domestic well on site ( y/ a } pVWjf) ♦ `� <br /> if yes, location and distance - V 7 <br /> ft. <br /> 3 <br /> SAMPLING <br /> Holding Temperature ✓L�j(�/ _ <br /> Method <br /> Screening Method _ <br /> Tracking Sheet C y/ n ) <br /> In � ;L. ♦ — T tL <br /> SPOILS <br /> Storage Method MATERIALS/D EVELO P%ENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location no Casing type <br /> Blank ft. Steen --ft- <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block. - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - C y/ a ) <br /> Type of method <br /> EH 29 29 <br />