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,,,,.vIONITORING WELL INSTALLATION REI T <br /> Date: ! 2 , 2 1 '9 112,,2 2 - f CONSTRUCTION <br /> Premise Address: 4 D lov Total Depth�_���' l <br /> Screen Length (from) G (to ly. <br /> Well No,: :� VV Filter Pack (from) 4 !� (to) .� <br /> �[ Bentonite (from) C` (to) <br /> 6 t- -- <br /> Inspector: i"1 Grout (frons) (to) <br /> Drilling rig type <br /> Permit No. - 2c) _ Auger O.D. Y.D. <br /> �R Completion - Stove pipe/citristie box (circle one) <br /> Drilling Company V�l`� -ll .._.._LZ } <br /> Driller. :Yov)n toss y' EC C� t r�s •l — p ���e casing <br /> rieir�ht <br /> Consultant O-Co tC� l <br /> Geologist �� 1� T <br /> ABOVE-GRCUND <br /> CX7A�I��"1`It,�M CHRZ7Y-80X <br /> COMPI.,MON <br /> SPECIAL PERMIT INFO, Ground Surfwt + .�� <br /> Distance to sewer line ti Grout <br /> Domestic well on site - j7y n ) 7 <br /> If yes, location and distance - ft. <br /> n. <br /> SAMPLING : a <br /> * cn <br /> Holding Temperature ocAe <br /> Method t IYUl(Q <br /> Screening Method ;c _ <br /> Tracking Sheet - y nLi <br /> ) <br /> SPOILS <br /> StoramiMethod tr Noted W d✓L)� E1 <br /> MATE RIALS/D V ,OPMENT <br /> Con <br /> Storage Location_-_ IS i Casing tree <br /> Blank ft. Screen ft. <br /> Slot size _ d <br /> GROUTING l3ags cement <br /> Buckets bentonite li ; <br /> Depth to water Bags sand/gravel /4 �a <br /> Mix Ratios Filter Pack t;pe/si e <br /> Installation Method Surge Block?7 y ) <br /> Quantity Installed Discussed with geologist: • n ) <br /> G t—y r Type of rncdiod Afl H(z".,e, <br /> EH 29 29 <br />