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MONITORING WELL INSTAL•LAnON REPORT <br /> �t-�. •� SS•Q,SsJ� • <br /> CONS-rRUcrION ale, <br /> Date: <br /> Total Depth <br /> Premise Address: fA� i Screen Length (from)_ (to) __ <br /> Filter Pack (from) (EO) <br /> — <br /> Well No.: Bentonite (from) (Co) <br /> �� � . Grout (fro r{i) (to) <br /> Inspector. Drilling rig type H <br /> Auger O.D. Z�} I.D. <br /> ipe/cllrisae box (circle one) <br /> Permit No. Completion - Stove p <br /> Drilling Company: <br /> �(^,r casing <br /> Driller: height <br /> Consultant .�► <br /> J v 1n r -- . <br /> Geologist J1'Z E-GRCl1N0 G},RSTY-30X <br /> GOMIPLEMN CIOM L==T1CN <br /> �• C3cW�Suiacs <br /> SPECIAL PERMIT INFO. prcz2 <br /> Distance to sewer line •i"�5 ,hPC <br /> �_..it. <br /> Domestic well on site - (y/ n) art • G Py ft. <br /> If yes, location and distance - I LA <br /> 1311 ' I 2�l 6� slorkd — <br /> SAMPLING Zd� ` soden <br /> V-1 = C <br /> S� <br /> Holding Temperature <br /> Method 3 <br /> Screening Method __ <br /> Tracking Sheet - (y/ n) -� 3' = 'fl. <br /> UF_ 6 20 ---ft' <br /> ac-s <br /> SPOILS �✓)Q Sv!►' <br /> ►ro�� MATERIALS/DEVEI.OPMENT <br /> Storage Method <br /> Contamination Noted- (y/ n) hp Casing type <br /> Storage Location � Blank--.ft. Screen <br /> L Slot size <br /> IIags cement <br /> GROUTING Buckets bentonite <br /> IIags sand gravel <br /> Depth to water �a Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/11) <br /> iputallation Method 1 P Discussed with geologist: - (y/ n) <br /> Quantity Installed I Type of method <br />