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ONITORING WELL INSTALLATION REPO# <br /> Date: I Ivhl CONSTRUCTION (� <br /> Premise Address: '7, IX Total Depth <br /> Screen Length (from) ' - (to) <br /> Well No.: V V 1 LO ( Filter Pack (from) '7L S (to) <br /> { Bentonite (from) 1 (to) <br /> Inspector.. COY f�f Grout (from)— T,,—,, _(to) Cj <br /> Drill <br /> Permit No. <br /> Auger tYg rig Pe O.D. I.D. <br /> Completion . Stove pipe/ sue box (circle one) <br /> Drilling Company: <br /> Driller: 7r7T casing <br /> height <br /> Consultant �- <br /> Geologist \ /. r 1r111t( n - r <br /> ABOVE-GRMNO Ct1RISTY 80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. G+nd SuAaa <br /> Distance to sewer line <br /> Domestic well on site . (y/ n) <br /> If yes, location and distance - ft, <br /> n. <br /> n. <br /> �q m <br /> V O <br /> C <br /> SAMPLING slorai = c <br /> aocisn _ <br /> Holding Temperature = R, ,I pack <br /> Method <br /> Screening Method <br /> Tracking Sheet • (� n ) <br /> SPOILS C <br /> Storage Method -'5S Do-f S MATERIALS/DEVELOPMENT <br /> Contamination Noted . (y n <br /> Storage Location Casing �� f�L Y <br /> Blank ft. Screen /c2� ft. <br /> Slot size <br /> GROUTING Bags cemen <br /> n I Buckets bentonite f :;?- <br /> Depth <br /> Depth to water O Bags sand/gravel re arm <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( yl,'/ n <br /> Quantity Installed Discussed with ge o tst: <br /> Type of method . <br /> EH 29 29 <br />