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r <br /> %--'MONITORING WELL INSTALLATION REP,...1T <br /> Date: lr4 4 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspectond kttg� 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 kam.'u I —CWT <br /> Geologist •� <br /> ASOVE-GROUND CHRIM43OX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surfac* <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) �_ - <br /> If yes, location and distance - ft. <br /> it. <br /> m <br /> — O <br /> SAMPLING $loft" = <br /> sacdon — <br /> Holding Temperature <br /> Method ` — I <br /> ack <br /> Screening Method =_ <br /> Tracking Sheet - ( y/n } — <br /> Ya• a.Y 1{. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - / 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 c 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 />