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"NITORING WELL INSTALLATION REPOF'" <br /> Date:— CONSTRUCE'ION <br /> PremiseAddress: <br /> �p S�} Total Depth ! I <br /> Screen Length (from) f _(to} <br /> Well No.: Filter Pack Cpm) J-9", _(to) ;;k-—/ <br /> Bentonite (from) (to) f <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit Na Auger O.D. :2 ( _ I-D. <br /> Completion - Stove pipe/ a box circle one) <br /> Drilling Company: <br /> DrilleCasing <br /> Driller. "�` �'` height <br /> Consultant <br /> Geologist ABOvE-GRcvND CHMST!•aOX <br /> ArPL�T+eN CCMPt_mCN <br /> SPECIAL PERMIT INFO. ri=nd Sufao* <br /> grout <br /> Distance to server line <br /> Domestic well on site ) <br /> / n ) ft. <br /> If yes, location and dis ce - K- <br /> it. <br /> - w <br /> C <br /> 0 <br /> SAMPLING z1or2d <br /> secicn <br /> Holding Temperature <br /> Method " _ <br /> Screening Method <br /> Tracking Sheet ( y/ n) . <br /> SPOILS <br /> Storage Method MATERIALS EVEL.OPMENT <br /> Contamination Noted - (y/ n r' L <br /> Storage Location Casing type <br /> Black ft Screen � K. <br /> Slot size • 0 <br /> GROUTINGr Bags cement <br /> i r 1 Buckets bentonite <br /> Depth to water r Bags sand/grave! 1.9- <br /> Mix Rados Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n } <br /> Quantity Installed Discussed with geologist: - C y/ n) <br /> Type of method <br /> EH 29 29 <br />