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MONITORING WELL INSTALLATION REPO;"r <br /> Date: do, /n. CONSTRUCTION y <br /> Premise Address: W Total Depth <br /> Screen Length (from) (to) <br /> Well No.: / �a3 C- 9 Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type NE 5 <br /> Permit No. 50 6 S 9 Auger O.D. g' I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> —� IffT <br /> �" <br /> Consultant ��y <br /> Geologist -'C-k <br /> ABOVE-GROUND (iiPLETIC <br /> 4= <br /> OONFLEfION <br /> SPECIAL PERMIT INFO. Ground S <br /> Distance to sewer line G �� stout <br /> Domestic well on site - (y h 17,5 ft <br /> If yes, location and distance - 46 ft. 39 <br /> — m <br /> = e <br /> = m <br /> SAMPLING sIottad -_ X. c <br /> Holding Temperature 17myw Pack <br /> Method <br /> Screening Method = "' <br /> Tracking Sheet - y n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) 2. <br /> Storage Location Casing type <br /> Blank 40 ft. Screen 10 ft. <br /> Slot size 020" <br /> GROUTING Bags cementJ J3 <br /> p& Il <br /> / Buckets bentonite z QI '1� �flt90 <br /> Depth to water l3 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size3 <br /> Installation Method Surge Block: - Oy n ) <br /> Quantity Installed Discussed with geologist: -On ) <br /> n) <br /> Type of method <br /> EH 29 29 A <br />