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YnONITORING WELL INSTALLATION REPOni <br /> Date: p p DD // CONSTRUCTION <br /> Premise Address : /1: C? s" Total Depth " 43 <br /> M W f 3 Screen Length (from) : (to) <br /> Well No. : Filter Pack (from) L (to) <br /> Bentonite (from) - (to) <br /> Inspector: a Grout (from) (to) > ( <br /> �, ` � 2Z Drilling rig type <br /> Permit No. Z 7 Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> DrillingCom/pany: Gy / ' , <br /> Driller: �/� O'\ ;4h � tikc �GX� casing <br /> � height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUN <br /> OONPLETION - / CNAIsTy-aox <br /> P <br /> SPECIAL PERMIT INFO. rd Surf � <br /> Distance to sewer line <br /> g '"bp� G;°T d <br /> Domestic well on site - ( y / n ) LC 1;o . <br /> N. <br />'I If yes, location and distance - I � .,. , 2 <br /> ( � <br /> Pt. <br /> SAMPLING slotted <br /> section <br /> Holding Temperature <br /> Method — v&W Pack <br /> Screening Method - <br /> Tracking Sheet - ( y / n ) <br /> 6 <br /> y � <br /> SPOILS <br /> Storage Me trod MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) 741 <br /> Storage Location Casing type Tn vC <br /> Blank ft. Screen K ft. <br /> Slot size 1020 <br /> GROUTING Bags cement <br /> Buckets bentonite / 'i Y <br /> Depth to water Bags sand/gravel <br /> Mix Ratios ff` Filter Pack type/size <br /> Installation Method c— N s +yt �'" Surge Block: - ( y / n ) <br /> Quantity Installed T Discussed with geolog st: - ( y / <br /> Type of method <br /> EH 29 29 <br />