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vr, <br /> :. WELL INSTALLATION REPOT.:: <br /> t• �; ib�. - = MONITORING _ _ <br /> ..Date:• w s �_ *� g ,: _ }CONSTRUCTION: k <br /> i <br /> Premise Address: - .Total Depth <br /> • \Screen Length (from) (to) <br /> . Well,No. Filter'Pack ?N(from) .' - �'� (to). `R <br /> Bentonite (from)- (to) <br /> i-.Ins ector.--- ...Grout _ , (from)_ (to) . <br /> ng type <br /> �-Permit No.­: _ ` _ _ Augcr.'O.D ., <br /> Y Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: - ~- - - ` <br /> 4 ; <br /> s i V �,y 1. .+�1� `4 r.� °'r i k E t p C S].I1CJ _. Y�`,' �G4 . <br /> Driller. - height <br /> Consultant_ <br /> I Geologist ..�: .. ,..A,_� •. <br /> /�BQYE•GFICUNC GiRJM43OX <br /> COMPLETION w •. COMPLETION <br /> SPECIAL PERMIT INFO, ` + ' G=W 5u la" graA <br /> .. <br /> Distance to sewer line <br /> Domestic well onsite (y/ n) <br /> If yes, location and distance _n _ T ' T y ft- <br /> . .-. �....� . r .�,_ ...,.,±-rw�,1 moi,, f.. � s -.. ,.- .. ��,. ,., ._ Av r »:, y.� �...... . r•i... <br /> SAMPLING . r <br /> cn <br /> Holding Temperature <br /> ` Method <br /> Screening Method t. v <br /> Tracking Shek - {y/ n ) <br /> .SPOILS - <br /> r <br /> Storage Method MATERIALS EvEI.OPMENT <br /> ` Contamination Noted - (y/n ) } <br /> Storage Location —Casing type �► <br /> _ Blanit !ft. Screen ft.. <br /> Slot size_ . . 3 <br /> :f GROUTING . Bags cement <br /> Buckets bentonite <br /> ` Depth to water .� ra Bags.sand/gravel' > <br /> Mix Ratios- - Filter-Pack type/size <br /> Installation Method - Surge-Block: - ( y/.`n } <br /> t .Quantity Installed - - - -Discussed with geologist: - (y/ n ) <br /> Type of method 1 + <br /> EH 29 29 <br />