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MONITORING WELL INSTALLATION REPORT <br /> Date: �� ZA7 CONSTRUCTION <br /> Premise Address:�i��°t•/ . y`f�°� Total Depth <br /> q - Screen Length (from) (to) <br /> L <br /> Well No.: � (� / bou -clepbf Filter Pack (from) (to) <br /> Bentonite (from)—(to)- <br /> Inspector:. <br /> from) (to)Inspector: K Grout (from) (to) <br /> Ca�g rig type <br /> Permit No. ger O.D. 1d 'f LD. <br /> Drilling Company: <br /> letion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> �+" height <br /> Consultant_Ali, rk <br /> Geologist-4,�— T <br /> ABOVE-GROUND <br /> COMPLETION CHRISTY-BO <br /> COMP N <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line Grp <br /> Domestic well on site - (y/n) ft <br /> If yes, location and distance - <br /> ft ft. <br /> = m <br /> SAMPLING = <br /> clotted — c <br /> acc4on = � <br /> Holding Temperature <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/n) ' <br /> SPOILS Al <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) j a <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot siz <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 method <br /> EH 29 29 <br />