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N .nONITORING WELL INSTALLATION REPG,.,.V <br /> ILI <br /> Date: I LI 71N CONSTRUCTION <br /> Premise Address:T� Total Depth / <br /> Screen Length (from) (5 " (to) 5' <br /> Well No.: 1 h Linw � -e Filter Pack (from) 6� (to) (p• <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) Y (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: cas ing <br /> height <br /> —qVTConsultant �-� ' C T7 T <br /> Geologist ABOVE-GROUND <br /> COMPLETION CtiCOMPLETION <br /> SPECIAL PERMIT INFO. around Surface <br /> Ft 1 L� <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) _ft. <br /> If yes, location and distance - ft, <br /> - ft. <br /> e <br /> �µj3,e <br /> SAMPLING gyp• sbctod <br /> �Ay sec5on <br /> Holding T mpera a ,� v:, _ qasat pads <br /> Method = S <br /> Screening ethod I r D Nn <br /> Tracking Sheet - (©/ n ) <br /> /) % = Iric ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted n ) <br /> Storage Location tyb) ---t- � kiln . Casing type v <br /> Blank S ft. Screen tU f�• <br /> Slot size 0.OZ.o <br /> GROUTING Bags cement L I S/�¢ <br /> Buckets bentonite <br /> Depth to water 6'�' � Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ <br /> Quantity Installed Discussed with geologist: - / n) <br /> Type of method <br /> EH 29 29 <br />