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MONITORING WELL INSTALLATION DEPORT <br /> Date: q1 71 CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.s Filter Pack (from) (to) <br /> VV Bentonite (from) (to) <br /> Inspector: rm';t&.a Grout (from) (to) <br /> Drilling rig type <br /> Permit No._60cl O Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company:_ M A <br /> Driller: TT casing <br /> height <br /> Consultant <br /> Geologist ._ <br /> ABOVE-GROUND <br /> COMPLETION CHRLM-BOX <br /> SPECIAL PERMIT INFO. Ground Svfacs COMPLETION <br /> Distance to sewer line Ofoul <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - n• <br /> it. <br /> = m <br /> C <br /> SAMPLING ° <br /> 6 j10 <br /> aacl n <br /> Holding T peratur `� L <br /> Method ua �"�Pack <br /> Screening Method _ <br /> Tracking Sheet - n ) <br /> SPOILS e n <br /> Storage Method MATERIALS EVEL PMENT <br /> Contamination Noted - r,,)/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bento to <br /> Depth to water Bags sand/ el <br /> Mix Ratios 1144- Filter Pack a/size <br /> Installation Method Surge Blo - ( y/ n ) <br /> Quantity Installed Discussed 'th geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />