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�T ONITORING WELL INSTALLATION REPOxC <br /> Date: CONSTRUCTION <br /> Premise Address: bU 1 Total Depth <br /> _ l Screen Length (from) y (to) Y <br /> Well No.: Filter Pack (from) a`Q (to) 3;1 _ <br /> Bentonite (from) 3T (to) <br /> Inspector: Grout (from) 95 (to) <br /> Drilling rig type <br /> Permit No. �U Auger O.D. R I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> Q� <br /> height <br /> Consultant G <br /> Geologist ABOVE-GROUND <br /> COMPLETION CHR7STY-BOX <br /> SPECIAL PERMIT INFO. Ground Sudan <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) 35 ft. <br /> If yes, location and distance - � tt <br /> Ltt _ <br /> = m <br /> — e <br /> _ <br /> SAMPLING siottad = <br /> taction — <br /> Holding Temperaturegmys,Pack <br /> Method = <br /> Screening Method <br /> Tracking y n <br /> Sheet - ( / <br /> SPOILS 50 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) a a / <br /> Storage Location Casing type 40 <br /> Blank mfr. tcreen /0 fr. <br /> Slot size W" \ <br /> GROUTING Reg*cement t�•� <br /> Buckets bentonite <br /> Depth to water Z Bags sand/gravel <br /> Mix Ratios 3$ -r Y7,3 Filter Pack type/si e L�3 <br /> Installation Metho a... u1 Surge Block: - <br /> Quantity Installed lL17c Discussed with geologist: - n ) <br /> Type of method <br /> EH 29 29 <br /> 1 � <br />