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,AONITORING WELL INSTALLATION REPOn <br /> CONS_., STRUCTION <br /> Dace: (} c7 <br /> . ✓ FSC".`tiD Total Depth to <br /> Premise Address: "7 Screen Length (from) 5__.. ---( ) - <br /> �A I ^ Filter Pack (from)__ 4:—�to� tY • <br /> well No: Bentonite <br /> (from) (to) <br /> (from) <br /> Inspector: �^ !' C. t a:y Drilling rig typetl ti „ <br /> Auger O.D. t Ci 15 L. <br /> — -- " —_ circle one) <br /> permit No.�1=c- /—/�� Completion -Stove PipLttisue box <br /> Drilling Company: casing - <br /> nz _ i �. height <br /> Driller. �^ it <br /> T <br /> Consultant <br /> C��+ int i l:. i,f° \1'1 +:S- F•'l <br /> )1 �_.--- <br /> ABOVE-GROUND CNRLSiI'-80X <br /> Geologist CoWLErX)N COMptEnou <br /> r.�Ground Surlicx <br /> SPECIAL PERMIT INFO. f25 ; rta L., 7A grout <br /> tet_ <br /> Distance to sewer line ��_fl. <br /> Domestic well on site - y/ n) �A 4 n• <br /> If yes,location and distant}- a -h•4 ,4 — <br /> P <br /> C <br /> O <br /> xioctad = S <br /> SAMPLING <br /> grxvnl Pack <br /> Holding Temperature r� 1 ----- <br /> Method <br /> Screening Meihod f, n„ <br /> Tracking Sheet - (y/ n) <br /> SPOILS <br /> G MATERIALSf9EVELOPMENT <br /> Storage Method .� , n, e _ <br /> Contamination Noted- ( !/n) rr a v T A�'t Casing type_ r T 1 <br /> Storage Location 5 I'd -A`P c `^� r L �' Blank I ft. Screen�1 _-- <br /> slotsize <br /> Bags cement <br /> GROUTNG Buckets bent-o_e � <br /> Bags sand/gravel__� <br /> Depth to water 1 1 _-- -� ts' 901n„1 Filter Pack type/size <br /> Mix Ratios N 9 ih •�`` ' " - 'A v.>'xT�� Surge Block: - (Y/#� <br /> Installation Methods Discussed with geologist: - Cly,/ n) <br /> Quantity Installed I 1 ,rA Type of method <br /> EH 29 29 <br />