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MONITORING WELL INSTALLATION REP".4 <br /> Date: / CONSTRUCTION <br /> Premise Address: ILO / • '05'/L/3ae'j Total Depth 170 <br /> Screen Length (from) (to) <br /> Well No.: P(to — 615 - 3 Filter Pack (from) (to) 6-7e <br /> Bentonite (from) (to) 6 ti <br /> Inspector: 5 . 5C.141,l0 j�)LL Grout (from) ( ti (tom <br /> Drilling rig type <br /> Permit No. 91 '1273 Auger O.D. Z 2 <br /> ' / Completion- Stove pi /chrisne bo (circle one) <br /> Consultantt� h lac <br /> Geologist rJlsY1-IJ i✓/9UFIC�✓�tZT1Jl�Z� stldcup <br /> in <br /> SPECIAL PERMIT INFO. Aj6VE-GROUND CHRary-BOX ' <br /> � i COMPLETION <br /> COMPLETION <br /> Distance to sewer line t3rout 4 Suiace �.r <br /> Domestic well on site - (y/� <br /> If yes, location and distance - PROtt <br /> fin. G n. <br /> m <br /> SAMPLING / c <br /> chi°L dotted <br /> Holding Temperature i — $ <br /> section <br /> Method <br /> Screening Method pV/'i __ gr"°I Pack <br /> Tracking Sheet - (y/ n) _ <br /> n _ n <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Notes - tj y7 n ) M[Nod- ^ Zit - c <br /> Storage Location 'cON S 17Zr Casing type S [�1 111 __ <br /> Blank �°t ft. Screen fr. <br /> Slot size OX0 <br /> Bags cement <br /> GROUTING Buckets bentonite DNI. <br /> [ \ Bags sand/gravel <br /> Depth to water_ "7 gu- 6OM/'''k WP/ Filter Pack type/size <br /> Mix Ratios Surge Block: - }P n) <br /> Installation Method Discussed with geologist: - (y/ n ) <br /> Quantity Installed Type of method �XiaUL / te?�uY&� FM- 3��+N• <br /> O-V5-) 71 xq I a � <br />