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1"iONITORING WELL INSTALLATION REPOiZT <br /> ���,U•�I i D-14 -as = <br /> Date: b Z �/ Ltd 9 ,l CONSTRUCTION <br /> Premise Address: i Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) Z (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) O <br /> Drilling rig type oqw <br /> Permit No. 6.35/ Auger O.D. I.D. I <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: �(il�u 4 casing <br /> Consultant w� height <br /> f <br /> Geologist - <br /> ABOVE-GROUND <br /> �( COM?LETION CNRISTY 80X <br /> SPECIAL PERMIT INFO. �` Ground Surf acs <br /> EJ <br /> Distance to sewer line « grout <br /> Domestic well on site - ( y/ n ) <br /> If yes, location and distance - S n. <br /> I , o <br /> SAMPLING M slotted <br /> aacaon .. — <br /> Holding Temperature <br /> Method P <br /> ack <br /> Screening Method 1> A- :a = <br /> Tracking Sheet n ) 4. <br /> SPOILS ,{ <br /> Storage Method / MATERIALS/DEVELOPMENT <br /> Contamination Noted n ) <br /> Storage Location Casing type <br /> Blank ft. Screen LO fr. <br /> Slot size .026, <br /> GROUTING Bags cement hw AW <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios --joFilter Pack type/size <br /> Installation Method 11 �Y1 I1Surge Block: - (y pogist: <br /> Quantity Installed M� Discussed with ge - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />