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1—MONITORING WELL INSTALLATION REPbWT <br /> JAAr„S 'S(Dcu� 4z ati.*- "J`o—O 3 <br /> Date: ' - CONSTRUCTION <br /> Premise Address: l _ �iY�- Total Depth ` J <br /> Screen Length (from) (to) <br /> Well No.: �S ' "2 S' S— Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No._9002 '-5to Auger O.D. 5,511 I.D. <br /> �� Completion - Stove pipe/cllristie box (circle one) <br /> Drilling Company: <br /> Driller: eAN � casing <br /> he_ght <br /> Consultant YY L U) ' V ` <br /> Geologist <br /> /ABOVE-GRCUND C7_iRlSTY-3OX <br /> COh9LETCN C0WIUTICN <br /> SPECIAL PERMIT INFO. Gcmnd Surfacs <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> _ r <br /> o <br /> SAMPLING slorad <br /> Holding Temperature r -_ gaud Fzxx <br /> Method =_ <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <: <br /> ir <br /> SPOILS <br /> Storage Method 5 '1!` � MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Blankg type ft <br /> ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Ba <br /> gs sand/gravel <br /> agaa�_ <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ 11 ) <br /> Quandry Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />