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MONITORING WELL INSTALLATION REP <br /> h (n , <br /> Date: COR 10 <br /> � n q ' M " "`Ldp• Total Depth <br /> ZS <br /> Premise Address: � ( \ l"n i �� r v � � p <br /> J Screen Length (from) L (to) 15 <br /> Well No.: Filter Pack (from) z1r (to) 12 <br /> 11 � Benconite (from) i 2 (to) <br /> Inspector. A) /J Grout (from) to) <br /> Drilling rig type 5— <br /> Permit No. <br /> lj Auger O.D. I_D. <br /> �! � Completion - Stove pipe✓ctu'istie box (circle one) <br /> Drilling Company: 7 1�6�-l f'Qr - <br /> Driller: �OY� r casing <br /> }� Ft 7 ,T <br /> height <br /> Consultant ! t <br /> c <br /> Geologist Crl ABCVE-GROUND <br /> 9 Crl4PL.=TION Cl�FtfST�'-3aX <br /> t�JMPt="ii <br /> urface <br /> SPECIAL PERMIT INFO. <br /> 1 <br /> 4t� <br /> Distance to sewer line <br /> Domestic well on site - (y/ n <br /> If yes, location and distance - z tL <br /> V 3 <br /> Q <br /> SAMPLING <br /> aectcn = <br /> O CHolding Temperature -::, _ 7xvW Pack <br /> Method - _ <br /> Screening Method <br /> Tracking Sheet - (y/ n) '?. <br /> ZT <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOP <br /> Contamination Noted - (y/ a) <br /> Storage Location Blackank type <br /> BlEt /..,Screen <br /> Slot size '(J <br /> GROUTING Bags cement <br /> t Buckets bentonite <br /> Depth to water, G _ Bags sand/gmvel F - <br /> Mix RatiosFilter Pack typ e <br /> Installation Method Surge Block: ( / n ) <br /> Quantity Installed Discussed wi geologist. n) <br /> Type of method <br /> EH 29 29 <br /> ho-ct -ro r <br /> I <br />