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MONITORING WELL INSTALLATION REPORT <br /> Date: 11 I� 3 /1 '1- CONSTRUCTION <br /> Premise Address: �� /A4/% 1 Total Depth 2- f�S 6 <br /> (, Screen Length (from) (to) <br /> Well No.: ./ G ► n 't Filter Pack (from) (to) <br /> 7 Bentonite . (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist 1t4 • <br /> 7 •- <br /> ABOVE-GROUND CHRtM43OX <br /> 1_1 COMPLETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) �_ft• <br /> If yes, location and distance - ft• <br /> ft. <br /> SAMPLING = <br /> slottad :�: — c <br /> sacdon — <br /> Holding Temperature9r1V1W Pack <br /> :v <br /> Method <br /> Screening Method ,x _ <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <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 /> Buckets bentonite <br /> Depth to water 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 />