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MONITORING WELT.INSTAR ATION REPORT <br /> r �w l Y GV9r• <br /> - <br /> 2 / G CONSTRUCTION <br /> Date* //�r,�J -� <br /> Premise Address: /L�"" " S -"cif �I Total Depth <br /> !, J Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No.: �[/ <br /> G Bentonite (from) (to) <br /> Grout (from) (to) <br /> Inspector: ,_ — Drilling rig type <br /> s / �� j Auger O.D. LD. <br /> Permit No. ,�J / Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: i" 17U4, <br /> casing <br /> Driller: e he_ght <br /> Consultant( l <br /> Geologist,. �� AE.C_ I -GRCIJND <br /> ppt,�SpLE7iOH C�IST•Y-20X <br /> co _EMN <br /> SPECIAL PERMIT INFO. Grwrd Sufis <br /> prccR <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - �- <br /> tt. <br /> �~ X <br /> C <br /> _ fl <br /> SAMPLING sforoi <br /> saricn <br /> Holding Temperature — <br /> viol_ - <br /> Method <br /> Screening Method <br /> Tracking Shcet - (y/ n) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - {y/ n) ID I) <br /> Storage Location Casing type <br /> Blank '_6 _fr- Screen IS'-- ft. <br /> Slot size . 6-20 <br /> GROUNG Bags cement */ °S ' <br /> TI <br /> Buckets bentonite-' h1-5 <br /> Depth to water Bags sand/gravel 24'12- <br /> Mas Filter Pack <br /> Mix Ratio type/size r '` <br /> �lnRation Method Surge Block: .. (y <br /> Quantity Installed Discussed v4th geologist: - y/ n )� G�7��.�e /3IMea <br /> Type of method <br /> EH 29 29r� ►� Cc'ltl✓����=, C'4/'S <br />