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v <br /> MONITORING WELL INSTALLATION REPOtc f <br /> Date: T Z Oo C. CONSTRUCTION <br /> Premise Address: ZD _t Total Depth / <br /> Well No.: Screen Length (from) (to) <br /> Filter Pack (from) (to)- <br /> Bentonite (from) (to)� <br /> Inspector: Grout (from) ( o) <br /> ��� (�G <br /> Drilling rig type— <br /> Permit No._ Q Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: __ �" casing <br /> Consultant <br /> height <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION COMPLCOMPLETI <br /> E--80X <br /> O <br /> SPECIAL PERMIT INFO. Ground Suri <br /> Distance to sewer line C- �� grout <br /> Domestic well on site - (y/ n) �N <br /> If yes, location and distance - ft. <br /> 57 <br /> SAMPLING slotted -= ' <br /> a G sac5on = <br /> Holding Temperature = Imp Pack <br /> Method <br /> Screening Method / <br /> Tracking Sheet y n ) <br /> ft. I,' —ft. <br /> SPOILS <br /> Storage Method — MATERIALS/DEVELOPMENT <br /> Contamination Noted - n ) L•r <br /> Storage Location Casing type <br /> Blank ft. Screen /0 ft. <br /> Slot size ,0ZO <br /> GROUTING Bags cement_ _C> _ <br /> Buckets bentonite_L G <br /> Depth to water 7iC� Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y n <br /> Quantity Installed Discussed with geo ogist: - (y <br /> Type of method <br /> EH 29 29 <br />