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MONITORING WELL INSTALLATION REPOR'�"'r <br /> _. �, o _ v •' -� . CONSTRUCTION � ,. • n <br /> Date: <br /> Total [ (to} rL + <br /> ` Premise Address: • ~ ""`" ` Screen Length (from) x. (to} <br /> ,V #`. a ri.w��✓ '` Filter Pack (from) - ---� <br /> u) / �s 3 <br /> T from) (to) <br /> 1. Well No.:` z "' Bentonite " ( (to) . <br /> Grout (from) T, <br /> Inspector: "''�� - _� Drilling rig tYp <br /> k` IF- <br /> .�I.D. <br /> w <br /> ! `4'; ► „, £ . z'a _._.. ._ <br /> Permit No. ' Completion - Stove pipe/christie box (circle one)" <br /> .DrillingCompany: <br /> casing .� <br /> Driller: he_ght " . <br /> Consultant Y t. <br /> GeologisRBOVE-GRCUND �O CHRM Y-BOX R <br /> COYPLET*N .• -C0MPt.__T1CN <br /> PERN[IT 1NF0— G=nd Sul=# <br /> # <br /> I�SPECIAL - . Of <br /> Distance to sewer line 2-� Y ft. <br /> Domestic well'on site - (y/ n) � ft, <br /> If yes, location and distance - <br /> kt <br /> i SAMPLING iioG�i y'% qi <br /> saslcn Vin' <br /> Holding Temperature : �. .:, ,. -r y — va{ - <br /> c Method 7 } <br /> t Screening Method <br /> ' Tracking Sheet -(Y/ n) <br /> .. . - •IN - <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> ,.Storage Method; . .- .1 <br /> Contamination Noted - (y/ n) <br /> Casing type �C <br /> '-.Storage Location <br /> ..,,...,.. .._ � ,�. BIanlc " Z �` ft. Screen,..._ <br /> Slot size 0•�� <br /> G '�TNG Bags cement <br /> ROU <br /> I - Buckets bentonite Y y <br /> Depth to water 3 Bags sand/gr <br /> avel <br /> Mix Ratios a� Filter Pack type/size <br /> Installation Method , . Surge Block: - (y/n ) <br /> Discussed with geologist: - / n) <br /> -Quantity Installed- <br /> Type Type of rncthod <br />