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MONI'T'ORING WELL INSTALLATION REP,,( <br /> So;C 30' soSa' <br /> � <br /> 2aa 2 <br /> Date: � CON UCTION <br /> M- <br /> C 5aytd nre K� <br /> Premise Address:– 11 ftft1 .Coral Depth <br /> Steen Length (from) (to) <br /> i Well No.: Filter Pack (from)_ (to) <br /> Benronire (from) (to) <br /> inspector Grout (from) (to) <br /> 'Drilling rig type <br /> Permit No. bre V .:Auger O.D. I.D. <br /> '.Completion - Stove.pipe/cnristie box (circle one) <br /> Drilling Company: <br />€ :DriIlercasing . <br /> f hez ght <br /> Consultanr j <br /> Geologist ABCVC-.GRC(Jzgo <br /> t� CCivF C i;CN CHSMT V-aax <br /> C�tv�PR..�'i'ICN <br /> SPECIAL PERMIT INFO. S ' <br /> Distance to sewer line 3 ! Z <br /> Domestic well -on site - ( y/ a } w x i <br /> If yes, location and distance - <br /> SAMPLING :igrrad <br /> aactcn -' <br /> Holding Temperature <br /> Method (� — <br /> k. _ <br /> Screening Method s " <br /> Tracking Sheet - C y/ n ) <br /> SPOILS <br /> y Storage Method MATERIALS/DI VELOPN ENT <br /> Contamination Noted - (y/ n ) Casing type . <br /> Storage Location Black ft Screen ft <br /> Slat size <br /> GROUTING Bags cement <br /> Buckets bentoaire <br /> ' I <br /> Depth to water Bags sand/gravei <br /> Mix Ratios b. Fuer Pack typesize <br /> 4nstaiiation Method Surge Block: - C y/ n ) <br /> a) <br /> Quwlrity Installed Discussed with geologist; - C Y/ <br /> (� y 4�/k <br /> e of method <br /> FH 29 29 �J1 It !O F3 <br /> h <br /> 40 �a' l -3 -�ar S - V <br /> i <br /> CL.— l S tmG 1` <br /> 6A Cq soy 4w, <br />