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MONITORING WELL INSTALLATION REPORT <br /> Date: IT I CONSTRUCTION <br /> Premise Address: `i L' 1[ Total Depth <br /> m I n Screen Length (from) '/ (to) <br /> Well No.: rT Filter Pack (from) 51 (to)._ /7 <br /> Bentonite (from) 3 (to) -'r <br /> Inspector: Ir( O Grout (from) (to) 3 <br /> p Drilling rig type � <br /> Permit No. o Auger O.D. X I.D. <br /> t� Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: --1 �T � )t'r' �� i '� <br /> Driller: casing <br /> /p� /r� height <br /> Consultant �I� b T <br /> Geologist_ P1A T <br /> ` ABOVE-GROUND CHRISTY-BOX <br /> V COWLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground SuAacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) '> - ft <br /> If yes, location and distance - ft <br /> n. <br /> m <br /> _ a <br /> c <br /> SAMPLING slotted <br /> soc5on <br /> Holding Temperature VavW <br /> ". <br /> Method '— P <br /> ack <br /> Screening Method c` =_ <br /> Tracking Sheet - ( y/ n) f( <br /> L7 Il. <br /> SPOILS <br /> Storage Method NA A eivv\--Z MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) rl n C <br /> Storage Location Casing type 1/ <br /> Blank ft. Screen /b ft. <br /> Slot size <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 />