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s,,,.ONITORING WELL.INSTALLATION REP(, <br /> Date: x CONSTRUC'T'ION <br /> Premise Address: J,57- Total Depth,_ zD — <br /> Screen Length (from) (to) <br /> Well No.: kl LA-y w Filter Pack (from)-- �10 _(to) 3 <br /> Bentonite (from) (to) /S <br /> Inspector: , Grout (from) /• (to) <br /> Drilling rig type <br /> Permit No, Auger O.D. ` I.D. <br /> J Completion - Stove pipe/ circle one) <br /> Drilling Company: <br /> Driller: casing <br /> he ght <br /> Consultant <br /> Geologist AZjOVj-:-GF10UND <br /> GOh�l,.ET�ON CNRtSTY-BOX <br /> SPECIAL PERMIT INFO. G=nd S`lwo <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n } -- ----- -ft. <br /> If yes, location and distance - R, <br /> #t. <br /> yr q <br /> d <br /> SAMPLING horn.! <br /> L�C <br /> sorScn - — <br /> Holding Temperature = Y� <br /> Method F <br /> Screening Method "h� — <br /> Tracking Sheet - (y/ n } 4. <br /> _ <br /> ft. ._.._... !t. <br /> SPOILS <br /> Storage Method MATERiALS/DEVELOPMENT <br /> Contamination Noted - n) 'r <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size t9 <br /> GROUTING Bags cement <br /> / Buckets bentonite <br /> Depth to water A&V 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 />