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MONITORING WELL INSTALLATION REPOI, <br /> Date:- Z CONSTRUCTION <br /> �� Q <br /> Premise Address: Total Depth_ <br /> Length (from) (to) <br /> � � w1JC�5 Filter Pack (from) _ (to) <br /> Well No.: <br /> Bentonite (from) (to) <br /> Inspector. �� Grout (from) (to) <br /> Drilling rig type <br /> Permit No. <br /> Auger O.D. I.D. <br /> ./ Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company:.VU <br /> Y_ casing <br /> Driller: height <br /> Consultant I��D <br /> q, <br /> 7, <br /> Geologist AE, -GRCUNO c4HnZITY-8CX <br /> CCkFL_FTION COLO r'TICN <br /> SPECIAL PERMIT INFO. Cxrc.nd Su•facs <br /> prat <br /> Distance to sewer line <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - ft• <br /> tt. <br /> — o <br /> SAMPLING iloroi <br /> sQcicn — J% <br /> Holding Temperature ¢'Y� <br /> Method _ <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> tt. y t2• <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type 541 <br /> Storage Location Blank ft. Screen i7 fr <br /> Slot size •�lv <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water �� Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) — <br /> Type of metliod <br /> EH 29 29 <br />