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MONITORING WELL INSTALLATI N REP <br /> Date: Q <br /> CONSTRUCI70N <br /> Premise Address: 4�; . Total Depth <br /> W Screen Length (from) (to) <br /> Well No.: Z ? 3 Filter Pack;; (from) (to) <br /> E Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig'type <br /> Permit No. Auger O.D.'1 I.D. <br /> Completion'- Stove pipe/du istie box (circle one) <br /> Drilling Company: <br /> Driller: t casing <br /> ii� height <br /> Consultant �/Qu'l T c-�-. Ua�l� Osl x v 111 <br /> Geologist .. <br /> p /4.84VE-GFtCglNO Gi-WtsTY-60X <br /> /' COP:�l.ET10I,1 <br /> PS ECTAL PERMIT INFO _ C3rourid Surfacs CMPLETICN <br /> �( <br /> Distance to sewer Iine <br /> Domestic well on site (y/n) # _}__,__�ft. ' <br /> I If yes, location and distance - ft. <br /> .IY <br /> SAMPLING <br /> Holding Temperature Y <br /> Method i/tJij Pack <br /> Screening Method N j� <br /> Tracking Sheet - / n) <br /> I' ft. <br /> f SPOILS M t <br /> Storage Method MATERIALS EVELOPMENT <br /> Contamination Noted - (y/ n } jI1) i <br /> Storage Location Casing VPee l /�� <br /> I Blank!° ft. Screen ft. <br /> Slot size I <br /> GROUTING Bags cement <br /> 3/ Buckets <br /> 1bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Nr4 Filter Pack type/size <br /> II, Installation Method Surge iBlock:i- ( y/u ) <br /> Quantity Installed Discussed with geologist: - (y/ n } <br /> Type of method <br /> EH 29 29 - <br />