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0 <br /> MONITORING WELL INSTALLATION REPOnf <br /> Date:—. �! CONSTRUCTION <br /> Premise Address: �� 04 "` Total Depth <br /> Screen Length (from (to)Well No.: Z Filter Pack (from) (to) S� <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type C~tT ' <br /> Permit No. Q Auger O.D. Add/2 I.D. 8 <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: t 3 casing <br /> c= T height <br /> Consultant ♦♦♦ <br /> T <br /> Geologist •- <br /> ABOVE-GROUND O}1AISl'1'-80X <br /> OOWLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line Orouf �,(ryryry <br /> Domestic well on site - ( y/ n ) ft <br /> If yes, location and distance - ' j� <br /> ft. <br /> — a <br /> = m <br /> SAMPLING slotted <br /> o <br /> &#cton <br /> Holding Temperature = P <br /> Method <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS J �(� <br /> Storage Method VIA" MATE LOPMENT <br /> Contamination Noted ( y ) <br /> Storage Location Casing type <br /> Blank ft. Screen /5' _ft. <br /> Slot size .020 <br /> GROUTING Bags cement ?)YA <br /> Buckets bentonitel <br /> Depth tow ter = Bags sand/gravel 2S <br /> Mix Ratio + Filter Pack type/size 3 7 <br /> Installation Method rtA aw�ti Surge Block: - ( y 1 <br /> Quantity Installed 25l _ 'hsh t O Discussed with geologist: - ( y/ n <br /> Type of method <br /> EH 29 29 <br /> .�-// � / / ✓�. Z <br />