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ivtONITORING WELL INSTALLATION REPOt. <br /> Date: l Q CONSTRUCTION <br /> Premise Address: �l9 :4:/ Total Depth Wb <br /> Screen Length (from) �Ib (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) 6 <br /> Inspector: `�` 5 Grout (from) (to) U <br /> Drilling rig type 75 1 <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 <br /> 7/, ffGeologist �&X k4:v' <br /> ABOVE-GROUND <br /> COWPLETCN Ct(AlSiY 80 <br /> C �! <br /> SPECIAL PERMIT INFO. Ground Surface <br /> KI- r/1 <br /> Distance to sewer line �rO� <br /> Domestic well on site - ( y/ n ) <br /> 1O L� <br /> ic <br /> If yes, location and distance - ft. <br /> �ft. n. <br /> r <br /> = m <br /> _ a <br /> = m <br /> _ o <br /> SAMPLING �C�A •lotted <br /> Holding Temperature = SSW Pack <br /> Method = <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) <br /> ft. ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank gO ft. Screen ID ft. <br /> Slot size Un" <br /> GROUTING Bags cement v N <br /> Buckets bentonite ` <br /> Depth to water-3 Bags sand/gravel ' <br /> Mix Ratios Filter Pack type/size ZVJ 2— <br /> Installation Method V;j U-j i Surge Block: - (y/ n <br /> Quantity Installed Discussed with ge gist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />