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MONITORING WELL INSTALLATION REP <br /> Date: 'Q CONSTRUCTION <br /> �� W• �,���� Total Depth <br /> Premise Address: (to) <br /> Screen Length {from) <br /> Well No.: �'l L) - �' Filter Pack (from) (to) <br /> � <br /> Bentonite (from) (to) 'I <br /> Inspector: <br /> {�ry� Grout (from) 37 (to) <br /> r ss�j <br /> Drilling rig type C <br /> Permit No. j Auger O.D. <br /> Completion - Stove pi /chrisUe box (circle one) <br /> Consultant �jts�Y�� <br /> Geologist stk*-Up <br /> SPECIAL PERMIT INFO. 4C, C'27CQ r-0119� ABOVE-GROUND CHRt,-BoX <br /> fk��AAFLEfiOf�! COMPLETION <br /> Distance to sewer line G=nd gurlace <br /> Domestic well on site - (y/0 <br /> If yes, location and distance - QtoA <br /> 1.r.+•- ft. <br /> • ft. <br /> ft. <br /> R%r <br /> - 4 0 <br /> �n O <br /> SAMPLING , _ <br /> a <br /> Holding Temperatures _ sl0 <br /> � , iK'Ri OM1 x <br /> Method 1 — <br /> Screening Method_ Ina—ek <br /> Tracking Sheet - ( n) <br /> r <br /> SPOILS - <br /> Storage Method r�'�� I(--- MATERIALS/DEVELOPMENT <br /> Contamination Notes - (&Y n } Is <br /> Storage Location N S Casing type '9- � <br /> Blank 2 & Screen /Sft. <br /> Slot size C� U <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water `t S Filter Pack type/size ;rZI,Z— <br /> Mix Ratios 4_W!A� f Surge Block: - W n ) <br /> Installation Method Irsti Discussed with geologist: - (0 n ) <br /> Quantity Installed Type of method rlrll <br />