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MONITORING WELL INSTALLATIONREPO <br /> f/ CONSTRU' - <br /> Date: / q <br /> / �/o Total Depth <br /> Premise dress: J <br /> Screen Length (from) (to) l <br /> Well No.:_ T��'�/ _ Filter Pack (from) (to). <br /> Bentonite Cfrorct}_/'5-(to) <br /> ector <br /> . Grout (from} 3,.��� .��(to) -,,I- <br /> Inspector. AAs/ _ <br /> {,n <br /> .Drilling rig type C f�t <br /> Si � U Auger O.D. r� I <br /> Permit No. - Completion - Stove pipe/ Zristie bo /(circle one) <br /> Drilling Company: cy"'G `l <br /> � casing <br /> Driller: GG F height <br /> Consultant �jfLy2rc�� -er .� Urdkr <br /> Geologist ASaVE-GFtCUNO <br /> coWLETCN 006011LEMN <br /> SPECIAL PERMIT INFO. G«,rd six. <br /> procct <br /> Distance to server line <br /> Domestic well on site - (y/ n) tt. <br /> If yes, location and distance - - <br /> .tea <br /> y- G <br /> d <br /> SAMPLING ifora.� <br /> secicn <br /> �r <br /> Holding Temperature <br /> Method <br /> :h <br /> Screening Method <br /> Tracking Sheet - (y/ n) s: — <br /> SPOILS <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted - (y/ n ) v[ <br /> Storage Location Casing type <br /> Blank fr. Screen 13 h• <br /> Slot size fl Zee - <br /> GROLITING Bags cement rel 4 - <br /> Buckets bentonite; <br /> Depth to water Bags sand/gravel " 3 <br /> Mix Ratios Filter Pack typesize -4--k-61- <br /> nstallation Method Surge Block: -�.J <br /> Zln } <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />