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MONITORING WELL INSTALLATION REPOn i -' <br /> Date: d 3 CONSTRUCTION <br /> 12-60 A). <br /> i. Premise Address: Total Depth Y <br /> Screen Length (from) <br /> Well No.: /�L�!/J s Filter Pack (from) 62- (to) <br /> Beritonite' (from) Z (to)— k <br /> Inspector: Grout (from) ! (to) 0 <br /> Drilling rig type Zi <br /> Permit No. Auger O.D. /D..5 I.D. <br /> f � Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: +V <br /> Driller: /C� fi casing <br /> 1, "height` <br /> f Consultant <br /> N' Geologist <br /> ILETIO <br /> Y-BOX <br /> �. Y � COIv�LET10N � <br /> SPECIAL PERMIT INFO. „ ""'» � ` ' ; " " G=rid Sisface <br /> k Distance to sewer line . �- grout <br /> Domestic well on site ='(y <br /> If yes, location and'distance - tL <br /> ft. <br /> ..= <br /> n SAMPLING <br /> on <br /> Holding Tempe <br /> rature *-C 4 ! <br /> Method <br /> Screening Method -e <br /> a ' Tracking Sheet - n') <br /> 'So <br /> SPOILS " <br /> r Storage Method J J a MATERIAL'S/DEVELOPMENT <br />` Contamination Noted f/ y <br /> Storage Location r 1 .It« . Casing type ),- . I/ <br /> larrlc 2S - ft.- Screen <br /> Slot size <br /> Ba cement # <br /> GROUTING t - r � <br /> " Buckets bentonite <br /> Depth to water` ° ' s Bags san'd/gravel ' <br /> Mix Ratios Filter Pack type/size <br /> Installation Method tr Surge Block: (y ` <br /> Quantity installed "Discussed with geologist: - (y� <br /> -d. Tyke of method <br /> EH 29 29I, <br />