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MONITORING WELL INSTALLATION REP-_':"T <br /> Date:� �Vor' CONSTRUCTION <br /> Premise Address: 5. A6 10'Z_ Total DeDth <br /> Screen Length (from) (t ) <br /> Well No.: Filter Pack (h'om) (to) <br /> '/ n Bentonite (from) (to) <br /> Inspector- 4*/,86 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 Comp <br /> Driller. cang <br /> pp � siheight <br /> Consultant V� <br /> Geologist�SJ� <br /> ABCVE-GROUND <br /> CC&V Fr;CN q-AtSTYoOX <br /> CCiNPL-i,CN <br /> SPECIAL PERMIT INFO. Groucd S+sf3cs <br /> Distance to sewer line grOLt <br /> Domestic well on site - ( y/ n } 1 <br /> If yes, location and distance - �- <br /> 3 <br /> - � o <br /> — a <br /> a <br /> SAMPLING 1=2d = <br /> wC:cn <br /> Holding Temperature = „ <br /> Method <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPN ENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING / Bags cement <br /> / Buckets ben nice <br /> Depth to water "-� Bags sand/ vel <br /> Mix Ratios IIAJ44 Filter Pack.type/size <br /> Installation Method Surge Block. - (y/ n ) <br /> Quantity Installed I/ AA/M/ Discussed with geologist - (y/ a) <br /> Type of method <br /> EH 29 29 <br />