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`. <br /> MONITORING WELL INSTALLATION REPOht' <br /> Date: t/t __ CONSTRUCTION <br /> Premise Addres( 15 Total DepthL <br /> Screen Length (from) <br /> Well No.:_ -� _ Filter Pack (from) (to) <br /> ((� Bentonite (from) (to) <br /> Inspector, � ttY-'L{- �, Grout (from) (to) <br /> / t ' Drilling rig type '- <br /> VS- <br /> permit No. Y Auger O.D. ffI " I.D. <br /> � Completion -Stove pipe/c s (circle one) <br /> Drilling Company: � J 1 /�" ' - r-rr <br /> Driller: IV- casing <br /> height <br /> Consultant s�YJ tLs t T f�' 3{L' TYMT <br /> Z T <br /> Geologist ) '�'" ABOVS-GROUND <br /> OOWLEfION Ct4a�rION <br /> COMPLETION <br /> SPECIAL PERMIT INFO, S e lacy — <br /> r l(/) ptcvt <br /> Distance to sewer line O'O' e "`= '4N ! )Flltr} <br /> Domestic well on site - n) I) 2j - n• <br /> If yes, locationand distance - fL <br /> � — c <br /> 0 <br /> SAMPLING dotted _ 8 <br /> aoc'ion <br /> Pack <br /> Holding Temperature QMVVI_ <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) ry _ <br /> SPOILS <br /> 7 _ MATERIALS/9EVELOPME <br /> Storage Method <br /> NT <br /> Contamination Noted - C /n) Mr 11 Casin <br /> .-„cetr-r C.,$npa/ GR” .MAf I{'C gtYP l <br /> Storage Location BlankT_ft. Screen /_�.f)__. <br /> Slot size ^ '7 <br /> GROUTING Bags cement r <br /> Bucketrtnnxtoirite <br /> Bags sand/gravel <br /> Depth to water 25 .y tle„5 Filter.Pack typesize �+ T <br /> Mix Ratios l n r v w f te; <br /> Surge Block: - (y/ n <br /> installation Method_ 3 Discussed with geologrst: - dy/ n) <br /> Quantity Installed I Fo E' Type of method <br /> EH 29 29 <br />