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MONITORING WELL INSTALLATION REP- A.T <br /> Date: d `�I, v � _ CONSTRUCTION / L <br /> Total Depth <br /> ?remise Address: V"i <br /> Screen Length (from) Cto) <br /> Filter Pack (from) <br /> Well No. : <br /> Bentonite (from) lSY (to) 665 <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Auger O .D. LD. <br /> Permit No. <br /> ' ( Completion - Stove pipe/cnristie box (circle one) <br /> j Drilling Comoanv- <br /> t ��A� Casing _ <br /> Driller.----�"�N� r he '_ghc <br /> Consultanty� ` � • <br /> Geologist6Ar�� ASCyE-GROUNO \ <br /> G„^Akv =TION CNRtS":'-oOX <br /> CC�MP�uCN <br /> Gtvund S+sf� <br /> i SPECIA.'_ PL�RMIT INFO . <br /> graA <br /> j Distance to sewer line <br /> j Domestic well on site • ( y / a ) O r It <br /> Ifyes , location and distance - t <br /> SAMPLING tO� <br /> aadcn — <br /> folding Temperature <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - ( y / n ) <br /> iY. ♦ — 7 It <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI OP VIENT <br /> Contamination Noted ( y- n ) Casing type <br /> Storage Location fc <br /> Blank ft Steen 2 <br /> Slot size /2 <br /> GROUTINGBags cement <br /> � L <br /> n Suckers bentonite <br /> Depth to water v � �Q Bags sand/gravel <br /> Mix Ratios Filter Pack typesize <br /> Installation Method Surge Block. - ( y n <br /> Quantity Insralled Discussed with yen o�isr: - C Y /0 <br /> Type of method <br /> EH 29 29 <br />