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MONITORING WELL INSTALLATION REP ae.T <br /> Date: CONS"tRUCT[ON <br /> ?rernise Address: X77 �� Tota! Depth 2-0 <br /> Sa-een Length (from) <br /> Well No.. I11 �i Z 3, q Filter Pack (from) (to) <br /> f Bentonite (from) (to) <br /> inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D_ I_D. <br /> Completion - SEove pipe/christie box (circle one) <br /> Drilling Company. <br /> Driller. casLng <br /> ;re L ghc <br /> Consultant, ' <br /> Geologist ,tSCY�-Gf�otlNi] <br /> SPECIAL PERMIT INFO_ G`°"rld Surfz" <br /> i <br /> groc.2 <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) `t• <br /> If yes, location and distance - it. <br /> y'Y a <br /> Q <br /> SAMPLING <br /> avcyars � <br /> Holding Temperature _T = <br /> 1Method <br /> Screening Method - <br /> Tracking Sheet - (Y/ n ) ' = <br /> n <br /> SPOILS <br /> Storage Method p,[ATERIALS/DEVELOPN ENT <br /> Contamination Noted - (Y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROU'T'ING Bags cement <br /> Buckets bentonite <br /> —I Bags sand/gravel <br /> Depth to water + <br /> Mix Ratios Fdter Pack type,/size <br /> Installation Method Surge Block: - (y/ n } <br /> Quantity Installed Discussed wig geologist: - C y <br /> Type of method <br /> EH 29 29 <br />