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MONITORING WELL INSTALLATION REPOnf <br /> ( Date: ,—�l/ W631. 5Ze� CONSTRUCTION <br /> f 11 <br /> i <br /> Premise Address: Total Depth <br /> / Screen Length (from) (to) 25 <br /> Well No.: (D Filter Pack (from) (to) ZS <br /> Bentonite (from) (to) <br /> Inspector: <a . Grout (from) (to)_ <br /> �+ Drilling rig type <br /> Permit No. / �0 3 U Auger O.D. 7r$ I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/christie box (circle one) <br /> Driller: V,// <br /> 'b T casing <br /> / height <br /> Consultant 7�J•��/i•L• <br /> RA T <br /> Geologist <br /> ABOVE-GROUND C-S:S7N-BOX <br /> CONFLETION LEno <br /> SPECIAL PERMIT INFO. Grourd Sumacs <br /> i <br /> Distance to sewerline grout <br /> Domestic well on site - (y ff / n <br /> If yes, location and distance - 5 ft <br /> ft. _ <br /> m <br /> — m <br /> m <br /> • o <br /> SAMPLING slowsecton <br /> _ B <br /> Holding Temperature - p <br /> Method <br /> Screening Method 'r? <br /> Tracking Sheet - n) <br /> Z5 ft. = n. <br /> SPOGLS <br /> Storage Method S5 MATERIALS/DEVELOPMENT <br /> Contamination Noted.; (y n ) Z n PVA <br /> Storage Location Casing type <br /> `Blank S ft. , Screen <br /> Slot size •dlA <br /> GROUTING Bags centaxt <br /> Buckets bentonite 2 G <br /> Depth to water - �" Bags sand/gravel <br /> Mix Ratios (((/// Filter Pack type/size - 3 <br /> Installation Method Surge Block: -(D n) <br /> Quantity Installed Discussed withgeologist: _ y/ ) <br /> Type of method ?SL,—yQ Ax— <br /> EH 29 29 <br />