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�NITORING WELL INSTALLATION REPO <br /> S' <br /> Date: A CONSTRUCTION <br /> '/ <br /> Premise Address: LY N "�h N'e�ulm Total Depth <br /> Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (to) <br /> _� Grout (from) (to) <br /> Inspector Drilling rig type <br /> 3 j Z) / �) ZZ Auger O.D. I.D. <br /> Permit No. Completion -Stove pipe/cluistie box (circle one) <br /> h <br /> Drilling Company: <br /> casing <br /> Driller. �� F height <br /> Consultant �S — \ ':' <br /> Geologist f ABOVE-GRCUND Ci 6 ZN-BOX <br /> CCMPIETION CCMPt._=71CN <br /> ...... nd Urfaca <br /> SPECIAL PERMIT INFO. <br /> arcut <br /> Distance to sewer line ft. <br /> Domestic well on site . (y/ n) n. <br /> If yes, location and distance - n <br /> tlonai � c <br /> SAMPLING sac'icn <br /> l UQpavelFadc <br /> Holding Temperature / -_ <br /> Method <br /> Screening Method — <br /> Tracking Sheet - (y/ n) ' - <br /> ft. <br /> n. _. . <br /> SPOILS <br /> Storage Method___=zL� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n) Casing type <br /> Storage LocatioBlank ft. Screen�ft• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> �G Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios Surge Block: - ( y/ n ) <br /> Installation Method Discussed with geologist: - ( y/ n) <br /> Quantity Installed Type of method <br /> EH 29 29 <br />