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MONITORING WELL INSTALLATION REP,r"'T <br /> Date: j I b CONSTRUCTION <br /> Premise Address: ( � Total Depth 4-S <br /> Screen Length (from) (to) <br /> Well No.: 3 Filter Pack (from) 46 (to) I <br /> Bentonite (from) i-L (to) <br /> Inspector: Grout (from) (to) <br /> r Drilling rig type / J � <br /> Permit No. Auger O.D. I.D. <br /> , \ � Completion - Stove pipe/ a box (circle one) <br /> Drilling Company- <br /> Driller: casing <br /> height —qv, <br /> Consultant � <br /> Geologist l� „�_ ._ <br /> /1E&E-GROUND <br /> GOMPLETCN C4_SZTY-8OX <br /> SPECIAL PERMIT INFO. Ground Surlw* COMPLETION <br /> Distance to sewer line Qfout <br /> Domestic well on site - ( y/ n ) ft <br /> If yes, location and distance - <br /> tt. _ <br /> SAMPLING = <br /> slotiad <br /> secton — <br /> Holding Temperature <br /> Method v"W P <br /> Screening Method IT) <br /> Tracking Sheet - ( y/ n ) <br /> L it. <br /> SPOILS <br /> Storage Method �� c MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) (i f� 1/ <br /> Storage Location Casing type ] V <br /> Blank S ft. Screen -3� ft. <br /> Slot sizey <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 />