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4� <br /> yorONITORING WELL INSTALLATION REPCrm� <br /> Date: CONSTRUCTION <br /> f / <br /> Premise Address: L{ I �" �� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: V W Filter Pack (from) /S _(to)�� <br /> Bentonite (from) (�� _ (to) <br /> Inspector: Grout (from) A-1 <br /> Drilling rig type <br /> Permit No. X Z7 Auger O.D. 10 T.D, i <br /> Completion -'Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> _r <br /> Driller: casing. <br /> heigjht <br /> Consultant �yO �` T " <br /> Geologist •- <br /> ABOVE-GROUND <br /> GOIPLETION <br /> 7-icoimprLno <br /> SPECIAL PERMIT INFO. Ground SuAwe <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> ft' <br /> If yes, location and distance - <br /> ��. ft. <br /> SAMPLING �lortad c <br /> aacxon " <br /> Holding TemperatureP <br /> Method <br /> ack <br /> Screening Method = <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) ` /p/> <br /> Storage Location Casing type Y <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> / i Buckets bentonite <br /> Depth to water� Bags sand/gravel &9'2- <br /> Mix <br /> LMix Ratios Filter Pack type/size 4T3 <br /> Installation Method Surge Block: - (y n <br /> Quantity Installed Discussed with geo gist: - (Cy/ n ) <br /> Type of method <br /> EH 29 29 <br />