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MONITORING WELL INSTALLATION REPOmf <br /> Date: rl� lf� CONSTRUCTION <br /> g16- <br /> r <br /> Premise Address{ Total Depth <br /> Y <br /> /rU n Screen Length (from)_[ (to) <br /> � <br /> Well No.: ,2 Filter Pack (from) / 5 (to) <br /> s Bentonite (from} (to) <br /> Inspector: �� + G r �=-fid 4(-"t4 ee Drrilling rig type&om) Cto) <br /> M <br /> Permit No. 6 Auger completion <br /> Stove <br /> " & it <br /> _ Completion - Stove pipe/ s e o (circle one) <br /> Drilling Company <br /> Driller &lcasing <br /> d0Y <br /> /� <br /> Consultant �t/un F <br /> Geologism& �fG 3 <br /> ABOVE-GROUND Ctiflts il'-Box <br /> COl.PLETION OOMPLE110N <br /> SPECIAL PERGrourd Surface � <br /> MIT INFO. <br /> proof <br /> Distance to sewer line i a 1 f <br /> n} I f hcrl h: <br /> Domestic well on site - y _ tL� <br /> If yes, location and distance - S ? w+y7 ft <br /> S X74 4 0 IN <br /> p <br /> alottcd ° <br /> SAMPLING 1 aecson — <br /> I" N — 7"Vro1 Pad` <br /> Holding Temperature hVIA <br /> % <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) IV i r� _ tt. <br /> tt. <br /> SPOILS <br /> jv,dt� MATERSALS/ETEVELOPMENT <br /> Storage Methods �sti�lar� d <br /> Contamination Noted - -4�n} M in r MlaPK@ Casing type i <br /> Storage Location-! � co t G Blank ft. Screen l__�-- <br /> Slot size <br /> Bags cement,) j <br /> GROUTING B -bentonite 3 Rr <br /> 1 3 Fa Bags sand/gravel <br /> _ Depth to water / 2}- yF1)cn5 Filter Pack type/size , "� 5 6 <br /> MixRatios Y-N i Lbs .+cs °F j t ° .T <br /> .�. `�'�fir Surge Block: - (Y n� <br /> installation Method -T Fa d Discussed with geologist: - (0 n ) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />