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"-MbNITORING WELL INSTALLATION REPOki.►' <br /> Date: ( � CONSTRUCTION <br /> ` / r <br /> Premise Address: ! ,00 i / Total Depth �- <br /> Screen Length (from) (to) 3 <br /> Well No.: L(� �- Filter Pack (from) (to 2, 2T <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) l 'la (to) <br /> I Drilling rig type llau) e, <br /> Permit No. Auger O.D. -1' g ' I.D. ` <br /> Completion - Stove pipe/ ' n 0x ircle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> ConsultantA) 7r=71 TTWM"7—" —W-T <br /> Geologist I,� ULw I/ V I u _o� <br /> ABOVE-GROUND CHRISTY4= <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> f ' <br /> Distance to sewer line 9f0'A <br /> Domestic well on site - (y/n) I I/'�- ' ft. <br /> If yes, location and distance - <br /> 3 n, <br /> SAMPLING slo6d _ Y� <br /> /� <br /> J Y <br /> aoc�on <br /> Holding Temperature <br /> Method 9 Pack <br /> �;. <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> IF ft. <br /> SPOILS <br /> Storage Method tivw MATERIALS/DEVELOPMENT <br /> Contamination Noted - y/ ) 0A0A s I re n <br /> Storage Location Casing type :P- f �C-- <br /> Blank 3 ft. Screen I5 ft. <br /> Slot size GROUTING Bags cement I 2— <br /> I Buckets bentonite '/�- <br /> Depth to water 3 Bags sand/gravel <br /> Mix Ratios _ Filter Pack type/size 3 <br /> Installation Method U Surge Block: - (y ell <br /> —D <br /> Installed Discussed with geo ogist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br /> 6 - 7 -a3 MWS <br />