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MONITORING WELL INSTALLATION REPOnf <br /> Date: I i CONSTRUCTION C� <br /> Premise Address: �lj /d "� Total Depth a" <br /> �� Screen Length (from) (to) <br /> Well No.: /�uZ'�t� Qy� Filter Pack (from) (to) <br /> ���'� 3 q <br /> /J Bentonite (from) 3 (to) 3) <br /> Inspector: Grout (from) 3 (to) <br /> Drilling rig type <br /> Permit No. � Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: <br /> I <br /> casing <br /> height <br /> Consultant //L0'�// � VZT- <br /> -' <br /> Geologist ABOVE GROUND <br /> COWPLETION COMPLETICN <br /> COMPLETION <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) R• <br /> If yes, location and distance - 3 ft• <br /> n. <br /> m <br /> — c <br /> o <br /> SAMPLING elattad = 8 <br /> wcyon —_ <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> ft. tt. <br /> SPOILS <br /> Storage Method ��� MATERIALS/DEVELOPMENT <br /> Contamination Noted - O <br /> Casing type <br /> Storage Location <br /> Blank o ft. Screen I0 h• <br /> Slot size_---!.o — <br /> GROUTING Bags cement <br /> ~ Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/s' 2 <br /> I <br /> Installation Method Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method_ p / <br /> EH 29 29 I IDASte�C1E 3p6�i <br />