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'"TVIONITORING WELL INSTALLATION REPOnl <br /> Date: �/- l� 7 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) 36 _ <br /> Well No.: �� ,Z/ Filter Pack (from) (to) <br /> kz <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) O <br /> (� Drilling rig type t L <br /> Permit No. 5'A2 Auger O.D. Eft I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: `• f ,' casing <br /> � <br /> height <br /> Consultant G� <br /> Geologist G���-G�--• � - ._ <br /> ABOVEGROUND <br /> COMPLETION C-SZTY-80X <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line `✓ grout <br /> Domestic well on site - (y n Z ft. <br /> If yes, location and distance - ��� Z ft. <br /> Jv ft. <br /> = m <br /> — b <br /> = m <br /> SAMPLING slcttad = c <br /> socton <br /> Holding Temperature _ vavW P <br /> ack <br /> Method =_ <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) <br /> ft. — I Fft. <br /> SPOILS j <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y 4 <br /> Storage Location_ Casing type (� <br /> Blank ft. S reen ft. <br /> Slot size . D " <br /> GROUTING Bags cement Z W II <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel 6 <br /> Mix Ratios -1 S r it2c4AA-- Filter Pack type/size 43 <br /> Installation Metho c c d Surge Block: - (y G) <br /> Quantity Installed 70 a •-+ Discussed with geologist: - (y,(S <br /> Type of method <br /> EH 29 29 <br />