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I- <br /> M NITORING WELL INSTALLATION REPO <br /> Date: ( CONSTRUCTION <br /> Premise Address: \T _ Total Depth <br /> Screen Length (from) �5 (to) 3 5 <br /> Well No.: U G2,2 Filter Pack (from) � (to) <br /> V 11 _r� Bentonite (from) 5 3 <br /> Inspector. �' rr Grout (from) (to) <br /> cam, Drilling rig type <br /> Permit No. 2� Auger <br /> q ,� 1 ,� Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: �)'�b� �`�� \/" `�` <br /> Driller: \oQJ��`e casing <br /> height <br /> Consultant <br /> Geologist -- <br /> ABC VE-G P LUNO ChA:S TY-30X <br /> CCMPL TCN CO4APL°71CN <br /> SPECIAL PERMIT INFO. Ground Surf <br /> Distance to sever line aroc. <br /> Domestic well on site - ( y/ n ) 3 ft. <br /> If yes, location and distance - 3,5. 33 ft. <br /> o <br /> SAMPLING slor2d <br /> soden _ <br /> Holding Temperature <br /> _ yravcl�fc <br /> Method <br /> Screening Method —• <br /> Tracking Sheet - (y/ n ) <br /> ft. V <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type `'12� PUC— <br /> Blank S J fr- Screen 2� fr• <br /> SIot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water sand/gravel 1,o l <br /> Mix Ratios (9e r icrype/size ��• �-� -� 2�i�- <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of mctliod <br /> EH 29 29 <br />