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4..ONITORING WELL INSTALLATION REPO,_/ <br /> Date: `J CONSTRUCTION <br /> Premise Address: ¢2`� L lCt�r /41YC!� Total Depth <br /> Green Length (from) (to) <br /> Well No.: M� ' Filte (from) <br /> Bentonite from} (to) <br /> Inspector: Grout (fro (to) <br /> Drilling ri e <br /> Permit No. r AuI.D. <br /> Co letion - Stove pipe/christie box (cir ) <br /> Consultant SLS f� <br /> Geologist f.)fd-,Xj MxT) - i�J stk*-up <br /> SPECIAL PERMIT INFO. ABOyE•GROU fl <br /> CNF1157Y4SOX <br /> Distance to sewer line r COMPLETION rid ace COMPLETION <br /> Domestic well on site - ( y/�) <br /> If yes, location and distance - grout <br /> ft. <br /> N 1± ft. <br /> SAMPLING <br /> Holding Temperature 4° slcstad ` <br /> Method r tZ_r C s�caon x <br /> Screening Method CSV t-1 = gravel <br /> Tracking Sheet - QV n) „. <br /> SPOILS <br /> Storage Method Ur`J C-# t11 L > MATERIALS/DEVELOPMENT_ <br /> Contamination Notes - (('y)/ n ) <br /> Storage Location U N '—stlT_ Casing <br /> Blank ft. Screen ft. <br /> Slot sizX()Bags ce <br /> GROUTING Buckets <br /> Bags sa <br /> Depth to water Filter P <br /> Mix Ratios 5 ? Surge B <br /> Installation Method 'M _ Discussist: - (y n )Quantity Installed Type of <br />