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,.,�NITORING WELL INSTALLATION REPOI,,_� <br /> Date: ( l I CONSTRUCTION <br /> Premise Address: a (50 Vy Total Depth a D <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) 0 (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to)' <br /> Drilling rig type 2 <br /> Permit No. ���� Auger O.D. 20 I.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Comlpany: <br /> Driller: \ Dim casing <br /> height--''� ' <br /> Consultant �t� l� <br /> GeologistCA <br /> i1`� <br /> ABOVE-GROUND CNAISTY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground S+xface <br /> Distance to sewer line ` _ grout <br /> Domestic well on site - (y ft. <br /> If yes, location and distane - <br /> v o <br /> SAMPLING sbroi :M; c <br /> saclon '– <br /> Holding Temperature <br /> Method (,r o �ir� e e- ` — Pack <br /> Screening Method P t A - <br /> Tracking Sheet - ( y/ n) <br /> J.ft. fte <br /> SPOILS <br /> Storage Method f-Y lM \ MATERIALS/DEVEI.OPMENT i <br /> Contamination Noted -)(Y)_n C <br /> Storage Location _ Casing type <br /> � �� Blank r ft. Screen ft. <br /> J Slot size <br /> GROUTING j Bags cement _ <br /> 7 2/ Buckets bentonite <br /> Depth to water 4J Bags sand/gravel <br /> Mix Ratios �o Filter Pack type/size <br /> Installation Methodr�r L ✓� Surge Block: -�y�/ n ) <br /> Quantity Installed _ Discussed wi geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />