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-.ONITORING WELL INSTALLATION REP ° <br /> Date: / r Z CONSTRUCTION <br /> Premise Address: • Vii! z�•4 Total DepthScreen Length �5 <br /> Well No.: Filter Pack {from) (to) 3'1 <br /> (from) 35 (to) Z 4 <br /> Bentonite {from)_ _ __(to) Z6 <br /> Inspector: //" Grout (from) 6 (to) <br /> Drilling rig type- ---ZZ711- <br /> Permit No. Auger O.D. <br /> Drilling Company-----'G ur�i"-�a ('� Completion - Stove pipe/ isae circle one) <br /> _ •r , <br /> Driller: ���_`�- casing <br /> height <br /> Consultant T <br /> Geologist w .� <br /> ABOVE-GRCUND C}MM-80X <br /> CONFLE ION c MPL-=nCN <br /> SPECIAL PERMIT INFO. G=nd gufact <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - <br /> v � <br /> SAMPLING <br /> L aL axlcn <br /> Holding Temperature <br /> Method = Tavel Pack <br /> Screening Method <br /> Tracking Sheet - {y/ n ) _ <br /> M <br /> SPOILS <br /> Storage Method Y_/�J. o MATERIAIS EVEI.OPMENT <br /> Contamination Noted - n ) <br /> Storage Location r' <br /> Casing type <br /> Blank / ft. Screen fr. <br /> Slot size ©Z 8 <br /> GROUTINGSlot <br /> cement <br /> �� Buckets bentonite <br /> Depth twater Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - {y/ Il ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> EH 29 29 Type of method <br />