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1 <br /> MONITORING WELL INSTALLATION REP----T <br /> Date: / 12004 CONSTRUCTION <br /> ( � I_'� Total Depth / <br /> Premise Address,. <br /> — l b Screen Length (from) (CO) <br /> Well No.: V 1 �� S t ` I� Filter Pack (from) Cto} <br /> �b Bentonite (from) Cto) <br /> �,O _ Grout (from) (to) <br /> Inspector. �— t Drilling rig type <br /> Auger O.D. I D <br /> Permit No. �j Completion -Stove pipe/christie box (circle one) <br /> Drilling Company: I <br /> LL casing <br /> Driller -Cer1 N�7�^^I <br /> height <br /> IN f 1 . <br /> Constiltant r <br /> Geologist_ pBCVE-.;ROUND �Z-1y-WX ' <br /> C.:bP—.rICN CJhiPt=ii CN <br /> GrWrA suf c <br /> SPECIAL PERMIT [NFO. � <br /> c � n <br /> Distance to sewer line 69- � � �R <br /> Domestic well on site - ( y L <br /> if yes, location and distance - <br /> r <br /> 73 <br /> a <br /> �b F7 2 <br /> t,d 'a <br /> SAMPLINGpack <br /> Holding Temperature -_ <br /> Method = I <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - (y/ n ) Casing type <br /> Storage LocationBly fr Screen <br /> Slot size <br /> NG Bags cement <br /> GROUTI <br /> I Bags a bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack typesize <br /> Mix Ratios Surge Block: - C y/ n ) x <br /> Installation MerhodDiscussed with geologis C y/ n) <br /> Quantity Installed Type of metlfQd <br /> EH 29 29 �/ <br /> 1 <br />