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MONITORING WELL INSTALLATION REPOt i <br /> Date: <br /> /l � CONSTRUCTION <br /> ��11 t <br /> Premise Address: �� l `" Total Depth o a <br /> r/ Screen Length (from) 80 (to) <br /> Well No.: / 7 Filter Pack (from) So (to)�_f <br /> Bentonite (from) S (to) !c .b <br /> Inspector: Grout (from) b .6 (to) O <br /> Drilling rig type CA^-E <br /> Permit No. �DAuger O.D. B I.D. <br /> - v <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company/: <br /> Driller: P / casing <br /> JQ6E height <br /> Consultant � <br /> Geologist Cnn�/ <br /> T ABOVE-GROUND CNRISTY-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Grourd Surf <br /> (ace <br /> Distance to sewer line <50 grout <br /> Domestic well on site - ( y,(Z> 6�,b n, <br /> If yes, location and distance - n, <br /> O <br /> _ O <br /> SAMPLING slotted <br /> an <br /> 40 <br /> Holding Tempera e e ys paw <br /> Method = <br /> Screening Method, D _ •` <br /> Tracking Sheet - n ) <br /> SPOILS <br /> Storage Method /vim MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Zu xK r <br /> / p✓e <br /> Storage Location IX 4&-Yt Casing type <br /> Blank fr. Screen 1c ft. <br /> Slot size • o <br /> GROUTING Bags cement_ q b&v Q �atl� <br /> Buckets bentonite " 90 <br /> Depth to water = IS Bags sand/gravel <br /> Mix Ratios Meal -t U5 11 Filter Pack type/size <br /> Installation Method_ Surge Block: - o n l <br /> Quantity Installed Discussed with geologist: - (L�n ) <br /> Type of method <br /> EH 29 29 <br />