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MONITORING WELL INSTALLATION REP <br /> Date: 20 - CONSTRUCTION <br /> r <br /> Premise Address:j-//CPW..—&A Al-&-� /c-j Total Depth—V{I`L _ <br /> �� Screen Length (from) Y (to) ayz, <br /> Well No.: Filter Pack (from) 2. 2 (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Permit No. " 0 <br /> 3W Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> ""..��--tE' <br /> Driller: Pk �f)&., casing <br /> Consultant <br /> 65C 4 height —Q <br /> Geologist A W <br /> ABOVE-GROUND CHRZ' Y-$CX <br /> COWLETION COMPLETION <br /> SPECIAL PERMIT INFO. G=rid$Urfa" <br /> Distance to sewer line AJ 0(cut <br /> Domestic well on site /n ) �,,._ft. <br /> If yes ocation and distance - M <br /> v m <br /> SAMPLING slormd <br /> o <br /> secicn <br /> Holding Temperature <br /> Method R c� _ Pack <br /> Screening Method__ P2� ,^„ •� — <br /> Tracking Sheet -�y-n <br /> - q Vz-fz. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n <br /> Storage LocationCasing type <br /> Blank ? z- ft. Screen <br /> Slot size r0 a o <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water L-5 3 Bags sand/graveI / QIF <br /> Mix Ratios,[ g Filter Pack type/s ze 3 a" <br /> Installation Method Surge Block: - n) <br /> Quantity installed Discussed with geolPgjst: n ) <br /> Type of method eell,�Z-111� <br /> EH 29 29 <br /> -P,4p cLm- -j L•rr►/ry <br />