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MONITORING WELL INSTALLATION REP&.@s <br /> '4 <br /> Date: <br /> 1 µ - CONSTRUCTION <br /> Premise Address•(�-5 5. Total Depth C7. <br /> Screen Length (from) CJ -(to)-Yo <br /> Well No.: Filter Pack (from) (to) <br /> J'L Bentonite (from) (to) � <br /> Inspector: �" - v : Grout (from) (to)77, arc. <br /> H+ Drilling rig type <br /> Permit No. CX�ZO q�f Auger O.D. .40" I.D. <br /> Completion - Stove pipe/clu-istie box. (circle one) <br /> Drilling Company. <br /> Driller:_ casing # <br /> Consultan�� T height <br /> _E Geologist ��' �a� � T <br /> ABOVE-GRVJND CH{;M-BOX ' <br /> COMPLEi 10N CCMPLE 1ON <br /> SPECIAL.PERMIT INFO. m . „ Ground Swfaca <br /> Distance to sewer line ��� � � �. - grout - .< <br /> Domestic well on site - (y/ n ft, <br /> If yes, location and distance - �� Yr��Gl <br /> SAMPLING •lorod <br /> t fa sac�cn <br /> HoldingTeeraure <br /> Pack <br /> Method <br /> Screening Method <br /> Tracking Sheet y n) <br /> SPOILS :< - <br /> Storage Method "�g MATERI6LS/DEW1.OPMENT <br /> Contamination Noted - (gyp <br /> Storage Location a Casing e <br /> Blank 0 ft. Screen 2-,0 ft'. <br /> Slot size <br /> GROUTING Bags cement 6 <br /> Buckets bentonite r <br /> Depth to water { L Bags sand/gravel <br /> Mix Ratios r�.G •�(> T 7XUAlt_ Filter Pack type/ ' 'z r z' <br /> Installation Method Surge Block: �n ) <br /> Quantity Installed - u . . Discussed with geologist: - � n) - <br /> Type of method <br /> EH 29 29r <br />