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SftpoNITORING WELL INSTALLATION REPOF <br /> Date•r P3 CONSTRUCTION <br /> Premise Address: /O 3 T Total Depth 20 <br /> z, 3 Screen Length (from) 2-el (to) <br /> Well No,: f Filter Pack (from) zo` (to) Y" <br /> Bentonite (from) '-F' (to) 2- 1 <br /> Inspector: Grout (from) z' (to) <br /> Drilling rig typ . <br /> Permit No, 77 C7 Auger O.D. b'7, I.D.7/V <br /> ` p Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing % <br /> height <br /> Consultant ���- <br /> Geologist_ -ol�►� <br /> ABOVE-GAC:UND ,� <br /> Ci:T10N CHFi�STY-BOX <br /> pMPL <br /> COMPtEnON <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line / grout <br /> Domestic well on site - (y <br /> If yes, location and distance - 24 <br /> �. <br /> aw M <br /> SAMPLING <br /> Vi <br /> o aecicn — <br /> Holding Temperature c' �. <br /> ;::: �ravd Fads <br /> Method 9A-,e� <br /> Screening Method �-W, <br /> Tracking Sheet y n ) <br /> SPOILS p <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted yon ) <br /> Storage Location-^ Casing type <br /> Blank ft. Screen <br /> SIot size �- <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water ��� Bags sand/gravel c� <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n <br /> Quantity Installed �(r __ Discussed with ge logist: (y n) <br /> �j Type of method <br /> EH 29 29 <br />