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d-NONITORING WELL INSTALLATION REP/'° T <br /> Date: / � / 1� C CONSTRUCTION <br /> n <br /> Premise Address:46 (in/' ) 1A >TX� VEL Total Depth <br /> yV,✓'d sT ✓�Il � , Screen Length (from) (to) <br /> Well No. : l Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: ^ Grout (from) (to) . <br /> Drilling rig type <br /> Permit No. Auger O.D. LD. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> J height <br /> ConsultantL <br /> Geologist, ©��` <br /> ABOVE-GROUND <br /> COMPLETION CHR1SfY-60X <br /> COMPLETION <br /> SPECIAL PERMIT INFO, Ground Suriacs <br /> Distance to sewer line grout <br /> Domestic well on site - ( y / n ) tt <br /> If yes, location and distance - <br /> _tt tt. <br /> c <br /> SAMPLING slotted = 8 <br /> ll% e. section `- <br /> Holding Temperature <br /> W'vel Pack <br /> MethodnTehodScreeniMtP <br /> Tracking Sheet - ( y / n ) <br /> SPOILS � r� utir ciC CA / S �t <br /> Storage Method ( ( MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y / n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> 77 Buckets bentonite <br /> Depth to water 1 7 ' 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 />