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I NITORING WELL INSTALLATIO,N REPO <br /> c <br /> Date: G ' l / CONSTRUCTION Y <br /> Premise Address: (o l 9�- W _ E `— Total'Depth' <br /> 16 <br /> Screen Length (from), (to) <br /> Well No.: "1 �' Filter"Pack (from) <br /> Bentonite I. (from) <br /> Inspector: Grout (fro (to) <br /> Drilling rig type <br /> Permit No. Anger O.D.`i 1.D. G�2a <br /> P i -m-eve rpuftlaistic box e ) <br /> Drilling Company: G1tsS�6 C I <br /> Driller: casing <br /> .11. height ; <br /> Consultant <br /> Geologist <br /> Ali.., - Ft " CiiR&M-BOX <br /> COt�t.ETION CCMPLE71ON <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line' flratt <br /> Domestic well onsite - (y n) � <br /> �' �i. (t, <br /> If yes, location and dis ce - i� i ft. <br /> ' <br /> ft.! <br /> SAMPLING Y. <br /> SAMPLING <br /> 510t'.e� <br /> aaczcn ' — <br /> Holding Temperature <br /> ack <br /> Method " -= ��F <br /> Screening Method — <br /> Tracking Sheet - (y/n } ^ — <br /> tt. <br /> SPOILS <br /> Storage Method vE�u�� IVIATEIUALS/DEVELOPMENT <br /> Contamination Noted - (y <br /> Storage LocationD Sbq = Casing type <br /> Blank ft. n ft. <br /> Slot size. '! I <br /> GROUTING Bags 11cement_ <br /> k <br /> Buckets bentonite <br /> Depth to eater Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method ?kl Md /4!1 - Surge Block: - n) <br /> Quantity Installed Disc with geologist: - (y/ n ) <br /> ype�i�of metliod <br /> EH 29 29 �i ; jJj <br />