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MONITORING WELL INSTALLATION REPv:cT <br /> Date:_61L1q CONSTRUCTION <br /> r <br /> Premise Address:3� 5'�"� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> ' �" � Bentonite (from) (to) <br /> Inspector:#�k- � Grout (from) (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: casing <br /> height <br /> Consultant 6"Pnr,r� _QV7F <br /> Geologist Lama Q •- <br /> ABOVE-GROUND CNAISTY-SOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/n ) 1 ft. <br /> If yes, location and distance - <br /> ft. ft. <br /> o <br /> = e <br /> c <br /> SAMPLING <br /> dotted _ c <br /> section <br /> Holding Temperature _ 9MYW P <br /> ack <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/n) <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />