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MONITORING WELL INSTALLATION REPOAi.! <br /> Date: (� CONSTRUC'T'ION <br /> Premise Address: Total Depth <br /> Sween Length (from) 5S (to) 3 S <br /> Well NoAW— ( Filter Pack (from) 5*5 (to) 33 <br /> Bentonite (from) 3 3 (co) 3 r <br /> Inspector, D-yft) Grout (from) (to) <br /> Drilling rig type <br /> Permit No. � Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: � �a���'�`-� <br /> Driller: I� r k�i '�(–'—'1 casing <br /> height <br /> Consultant l – <br /> Geologist <br /> ABCVE-GRCUNO Ct RZTY_8OX <br /> OO NV L.cTCN p� <br /> SPECIAL PERMIT INFO. G=rd Stsiacs <br /> prcvt <br /> Distance to sever 1' e <br /> Domestic well on site - / n) <br /> If yes, location and dis nce - t7 5,5 <br /> Y � <br /> - M <br /> O <br /> SAMPLING i(oroi <br /> sac-icn - <br /> Holding Temperature = V+YSol F— <br /> Method = <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATEWALS/DEVELOPMENT <br /> Contamination Noted - {y j n <br /> Storage Location Casing type <br /> Blank--:';S S fr- Screen z o fT <br /> Slot size <br /> GROUTING Bags cement 0206 Q <br /> Buckets bentonite <br /> Depth to water Bags sand/gravclWT <br /> � #�(�-2 <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 />