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MONITORING WELL INSTALLATION REP <br /> '- Date: rJ ' 15 ' t 2 CONSTRUCTION <br /> Premise Address: � �`"� I !y — Total�Depth� <br /> M1� Screen Length (from) '7� __(to) 4 <br /> Well No. _- Filter.Pack k (from) 2.0 (to)_ <br /> -- Bentonite ` (from) 3 ,.(to) � <br /> Inspector. �' S Grout (from) Z (to)— t> - <br /> 2 Drilling rig'type <br /> Permit No.� �' 3 Auger O.D. I.D. <br /> Completion�r- Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> I i. <br /> Driller: f�C.11�1�� Scot- -Sf-D h casing <br /> Consultant <br /> D C 1 height <br /> T- <br /> Geologist- <br /> ABOVE-GROUND WY-Box <br /> SPECIAL PERMIT INFO. Ground Sumacs k <br /> grout <br /> Distance to sewer line i. <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - �' ,it <br /> t <br /> SAMPLING aiov9d — <br /> �' sacticn <br /> Holding Temperature #e _ <br /> Method ` — <br /> Screening Method <br /> Tracking Sheet <br /> �.:..,..esY. ter...... n. <br /> SPOILS } <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Note • (y n -2— <br /> Blank <br /> { <br /> Storage Location — Casing type) r �I{ <br /> ,7�bC, ?3 Le 5D[ I�j e X, {C� `� Blanit ft. Screen 1S --ft• <br /> �1LUllL j �,l Slot size II D. b I <br /> GROUTING Lt �l.Y Bags"cement 1 <br /> s Buckets bentonite <br /> Depth to water Bags;}sand/gravel <br /> Mix Ratios Filter:Pack type/size 3 <br /> Installation Method Surge Block. - (y/ n <br /> Quantity Installed Discussed with geo ogist: - n) <br /> Type sof method <br /> EH 29 29 <br /> VIIIfl <br /> 13;W <br />