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'MONITORING WELL INSTALLATION REPOICt <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth 41 <br /> Screen Length (from) 42 (to) TZ <br /> Well No.: Filter Pack (from) 4-1, (to) ?.a <br /> Bentonite (from) ?,p (to) tg <br /> Inspector. Wtf' Grout (from) (to) U <br /> Drilling rig type <br /> Permit No. Auger O.D. (,Q I.D. (I. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller• casing <br /> height VCM ConsultantGeologist <br /> ABOVE-GACUND COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface •�•e <br /> Distance to sewer line Grout <br /> Domestic well on site - (y/n) <br /> If yes, location and distance - ft. <br /> ��. ft. <br /> SAMPLING slored <br /> d &Galen <br /> Holding Temperature <br /> Method Pack <br /> 1�� �Y� <br /> Screening Method <br /> Tracking Sheet - (V n ) <br /> (�� s• <br /> SPOILS Z <br /> Storage Method N MATERIALS/DEVELOPMENT <br /> Contamination Note /• y n ) •' <br /> Storage Location _ Casing type ?NL SGA-p 4o • 4 <br /> 'W�>_ 1 I Blank - I%, ft. Screen <br /> Slot size O.etc> <br /> GROUTING Bags cement <br /> Buckets bentonite l— C-O-t if S <br /> Depth to water Bag sa avel <br /> Mix Ratios 5 Filter type/ ' e <br /> Installation Method — Surge Block: - ) <br /> Quantity Installed Discussed with gist- - n ) <br /> Type of method <br /> EH 29 29 <br />