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MONITORING WELL INSTALLATION REP f <br /> Date: /o/1-9. /o U o ! /o ( 0/ > ' CONSTRUCTION <br /> 4 E m�.c�yP <br /> Premise Address: L Tdtal Depth <br /> ' " < - Screen Length (from) (to) <br /> Well No.:'/ f4 I 4/Z ` E /�J-� i, "� "Filter Pack,; (from) (to)' <br /> Bentonite, ._ (from). _ (to) <br /> \ Inspector. - ; Grout - (from)77 (to) <br /> 6 Z/o Drilling rig type <br /> Permit No, 1/3 s < Auger O.D. LD, <br /> Completion -Stove pipe/chnsue box (circle one) <br /> \\ . 'Drilling Company:'d�GG�i <br /> Driller: casing <br /> height <br /> Consultant . 2'"� <br /> -.\Geologist `« ' ttsL� <br /> ABOVE-GROUND <br /> Ilk � •'�-C . -- , 5 'A; -q•-.,,r�v4'•"FK C;C• COMPLETION CHSZTY43OX <br /> COMPLETION <br /> SPECIAL PERMIT INFO y �\ s +.' ` r * Ground Surface: h <br /> Distance to sewer.line- <br /> Domestic well on site �(y/ n`) <br /> If yes,location and distance - <br /> 1 7L <br /> t <br /> Z. _2c slotted t <br /> SAMPLING C;$ <br /> Holding Temperature i <br /> Method — <br /> Screening Method <br /> Tracking.Sheet - (y/ n ) M1 <br />� -u.Y\` ,. '•�. :-•{<.-.�� /�/f/fid` �°/ �"�~r � —L!�n' � _ � n. <br /> w SPOILS \\\y <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) .\ 4; ` <br /> Storage Location °i Casing type <br /> "Blank i.E' ft.. Screen 1C� fr. <br /> t",A— 'L a_��' -_b•:a� �wv t< . 1 \Slotsize <br /> V <br /> GROUTING Bags cement <br /> + 'Ic' �. NA �< t� '� \ '�,"` Buckets lientnn,rP brf-LD` <br /> Depth to water ` - r. . . •=r e r q Bags sand/gravel 2 c./Z_. +'� <br /> Mix Ratios \1 } Filter Pack type/size ' <br /> i Installation Method Surge Block: =,(y/ m) <br /> Quantity Installed Discussed with geologist: - (y/n ) <br /> k Type of method <br /> r'i �. ° \tic e h \�3 �-•. < 0 <br /> -a/S -�� Lbj3 �3 <br /> I <br />