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MONITORING WELL INSTALLATION REPORT <br /> Date: ''Z' I�L 6��� CONSTRUCTION <br /> Premise Address: �(`( �,�„ , Total Depth 5 5 <br /> Screen Length (from) (to) <br /> Well No.: nR W z Q1 Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from)_ (to) .3 . <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:_ /1n A casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CHRtM43OX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) 3 ft <br /> If yes, location and distance - <br /> 3 Cift. <br /> - C <br /> SAMPLING = ° <br /> slotted <br /> aacaon — <br /> Holding TemperatureLoy <br /> Method v"�pack <br /> Screening Method <br /> Tracking Sheet - (y/n ) <br /> .n- <br /> q-0 <br /> ft. ' — n <br /> SPOILS <br /> Storage Method S S—011J A�In mA MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ ) <br /> Storage Location cs 1pl� ".l Casing type Z \ P VC <br /> Blank ft. Screen O ft. <br /> Slot size_ ' 00 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water_ ' L Z- ' Bags sand/gravel Z <br /> Mix Ratios N 6rc _ , q -�_ �o..t CT7 Filter Pack type/size <br /> Installation Method ��iV Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />