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SVONITORING WELL INSTALLATION REPG,,� <br /> Date:/// / CONSTRUCTION <br /> Premise Address: J (.( Iht" G Total Depth <br /> ` � Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to)�.���� - . Bentonite (from) (to) <br /> Inspector: �(i Grout (from) (to) <br /> Drilling rig type <br /> Permit No. go Auger O.D. I.D. <br /> / Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> `��� T77 height <br /> Consultant C p�` T <br /> _W <br /> Geologist �ell • Wl <br /> ABOVE-GRCUND CMM-BOX <br /> COAFLETCN COMPLETION t>7 <br /> SPECIAL PERMIT INFO. Ground Surixs <br /> Distance to sewer line <br /> Domestic well on site (y/ n) <br /> If yes, location and dist ce - 5 <br /> . _ Lti <br /> - f 0 Lj <br /> a31z � 3 <br /> SAMPLING <br /> p sbr. <br /> "ftodcn ,* - <br /> Holding Temperature <br /> Method v�-r� c r�1u� 'n_e M1 � .7 n_Herr.. _ gm Gam' 6 S <br /> Screening Method F _r) L • _ .��E <br /> Tracking Sheet ( / n ) ` — S- 'Ira AA <br /> SPOILS <br /> Storage Method MATERIALS/DE LOPMENT <br /> Contamination Noted - (y n) <br /> Storage Location J ab u- Casing typ <br /> Blank ft Screen ft. <br /> Slot size <br /> GROUTING Bags ce ent <br /> i Lucke bentonite <br /> Depth to waters Bags and/gravel <br /> Mix Ratios i C� Filte Pack type/ ze <br /> Installation Method Sur a Block: - ( / n ) <br /> Quantity Installed /7,�,tc_ Di cussed wit geologist: - (y/ n ) <br /> 4 T e of meth d <br /> EH 29 29 <br />