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OONITORING WELL INSTALLATION REPO <br /> Date:_ Q[I�'OlZ�fr CONSTRUCTION <br /> Premise Address: .Cc.,...Q, r7 <br /> Total Depth <br /> Z <br /> Well No. t �i3 Screen Length (from) (to) <br /> : Filter Pack (from) (to) <br /> Inspector: Bentonite (from) (to) <br /> Grout (from) (to) <br /> 5� Dd '� �� Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> D'filling Company: Completion - Stove pipe/christie box (circle one) <br /> l <br /> Driller: <br /> casing <br /> Consultant <br /> /. G 7— height <br /> C ro, <br /> Geologist <br /> /180VE-GACUND <br /> CCMPLETICN CHRZTY-aOX <br /> SPECIAL PERMIT INFO COMPL-=TICN <br /> Cirocmd Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> _ m <br /> b <br /> SAMPLING PA = o <br /> soden _ <br /> Holding Temperature — <br /> Method __ VXV"W Pack <br /> Screenin;Method 1 = <br /> Tracking Sheet - (y/ n ) _ <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted - ( y/ n ) -- <br /> Storage Location Casing type <br /> Blank ft. Screen fr, <br /> GROUTING Slot size <br /> Bags cement <br /> " /G Buckets bentonite <br /> Depth to water_ ✓ <br /> Mix Ratios Bags sasand/gravel <br /> InstallatioFilter Pack type/size <br /> n Method Surge Block: - ( y/ ti ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> EH 29 29 <br /> Type of method <br /> — <br />