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- UONITORING WELL INSTALLATION REP <br /> - <br /> Date: Z l {� J CONSTRUCTION <br /> Premise Address:: Total Depth <br /> Well No.:- V �1 - Screen Length (from) a9 (to) <br /> / <br /> Filter Pack (from) (to) I <br /> Bentonite (from) I (to) IS <br /> Inspector. ��J2 Grout (from), (to) --C) <br /> Cj 2 l C) Drilling rig type t LOP <br /> Permit No. Auger O.D. q4 I.D. <br /> Drilling Company: � <br /> '! 1 ' ��J 1 Completion - Stove pipe/cluistie box (circle one) <br /> f— � J <br /> Driller: M(4 t J&G& g L) �� casing - <br /> 3!T- <br /> ABOVE-GROUND <br /> Consultant (� I - height <br /> Geologist YC."U'G (^C�n� [ K— <br /> COMPLETION CHRIM.80X <br /> COMPLEnON <br /> SPECIAL PERMIT INFO. Oroond SuAan <br /> Distance to sewer line graft <br /> Domestic well on site - (y <br /> If yes, location and distance ff. <br /> J_ft. ft. <br /> A = Y <br /> e <br /> SAMPLING <br /> 0 <br /> slorei _ <br /> v�� sedcn <br /> Holding Temperature _ _ qM,W PackMethod n <br /> Screeninx M thou <br /> Tracking Sheet - n ) �� <br /> 7 <br /> SPOILS , AWL <br /> Storage Method AVX AWL L MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/nz 2� <br /> Storage Location Casing type <br /> Blank lq ft. Screen <br /> Slot size UZp <br /> GROUTING Bags cement <br /> �� e�O�� Buckets bentonite <br /> 0 ' <br /> Depth to water N ��f ,� 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 />