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0 MONITORING WELL INSTALLATION REP. &T <br /> i <br /> Date: 20 o CONSTRUCTION <br /> Premise Address: 4rpm a �� Total Depth <br /> / —_� SeeLength (from) 4 (to) <br /> Well No. : w <br /> Filter <br /> Pack (from) Cto) <br /> Benronite (from) o (to) 'r <br /> /I ,Inspector: ® Grout (from) (to) J <br /> e� Drilling rig type eU �o b 4 _ <br /> Permit No. Auger O.D. I.D. <br /> � � \ Completion - Stove pipe/christie box (circle one) <br /> Drilling Company J <br /> Driller. C i 1 ✓I S casing <br /> height <br /> Consultant We IlY 1L ' ` Fr77 <br /> Geologist /� � � ABCVEr,ACUNO + - <br /> u I� <br /> q¢i <br /> CCW ET1ON COMtSTY-20N�� L P <br /> SPECIAL PERMIT INFO. ° GO"ndSurfaca <br /> aP <br /> Grout <br /> Distance to sewer line s <br /> Domestic well on site - ( y / n ) <br /> If yes, location and distance - ft. <br /> a <br /> SAMPLING <br /> wcdon . <br /> Holding Temperature yawl pads <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y / nIF <br /> ) <br /> SPOILS All Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> 1 Buckets bentonite <br /> Depth to water�� Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y / n ) <br /> Quantity Installed Discussed with geologist: - ( y / n ) <br /> Type of method <br /> EH 29 29 <br />