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ONITORING WELL INSTALLATION REPOn` <br /> coNs�oN <br /> Date: <br /> Total Depth <br /> premise Address: �/� Screen Length (from) Z_7— <br /> Filter Pack (from) <br /> !� Bentonite (fro -Z�g —(to)� <br /> Well No.: `AEm) <br /> from)�(to)�— <br /> Grout ( <br /> Inspector: Drilling rig type >Auger O.D. .D. <br /> Dv (�b _� <br /> Permit NO.------/ Completion - Stove pipe/chrtstie box (circle one) <br /> ,a <br /> Drilling Company: — casing <br /> ? a-- height <br /> Driller: <br /> Consultant 1�A T <br /> /„•,�� 9o�z�f9t�v9� Aj0VE•GR0UN0 C-SSTY•80X <br /> Geologist mow'^ COf,.qL [ION OMPL T10 <br /> Grourd Surface <br /> SPECIAL PERMIT INFO. grout <br /> Distance to sewer line tt- <br /> Domestic well on site - (y n tt• <br /> If yes, location and distance - tt. <br /> = a <br /> — m <br /> = o <br /> — m <br /> — c <br /> = o <br /> flatted = $ <br /> SAMPLING iacto" <br /> o G _ gravel peat <br /> Holding Temperatuhe _ <br /> Method 5Di� — <br /> D <br /> Screening Method y n) _ <br /> Tracking Sheet <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method <br /> Contamination Noted - Casing type— <br /> Storage <br /> n Casing type <br /> Storage Location c Blank g eft• Screen 1---� <br /> Slot size .O <br /> Bags cement Z <br /> GROUTING Buckets bentonite = 2- <br /> .GROUTING <br /> Bags sand/gravel <br /> Depth to water il• Filter Pack type/size <br /> Mix Ratios T Surge Block: - (y n <br /> 6 ' <br /> Installation Method mt� Discussed with geo ogist: - (Y n <br /> Quantity Installed Z Type of method <br /> EH 29 29 <br /> / <br /> !D- 5• D 3 �i l� (ew <br />