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__MONITORING WELL INSTALLATION REPO. <br /> Date: <br /> ` 3 / CONSTRUCTION <br /> � <br /> Premise Address Total Depth <br /> /�G✓/ - Ov`�/� � � 9.��'/�z�-,)t� � J Screen Length (from) (to) <br /> Well No ` ('� Filter Pack (from) (to) <br /> /S Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> I C� Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist •� <br /> ABOVE-GROUND CHSM1Y480X <br /> COAFLEf ION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> ft. <br /> b <br /> c <br /> SAMPLING slotted = c <br /> section <br /> Holding Temperature <br /> graV91Pack <br /> Method — <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> ft. -- ` Z" ft. <br /> SPOILS <br /> Storage Method m %(L ICA^ l"�� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y7 ) i•Gvi c <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size 0.0) <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel r Z <br /> Mix Ratios A,,I Q 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 />