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�NITORING WELL INSTALLATION REPO 19 <br /> IZ / /4 � CONSTRUCTION <br /> Date: �y <br /> �?j Total Depth qC) <br /> Premise Address: �J� , 1 Screen Length (from) (to) <br /> Well No.: � - \w Lf Filter Pack (from) (to) <br /> i Bentonite (from) (to) <br /> Inspector: J �' V�/ a Grout (from) (to) <br /> Ins <br /> P Drilling rig type <br /> 01 �3 Auger O.D. I.D. <br /> Permit No. e Completion- Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> y�� /� � � height <br /> Consultant r' T <br /> Geologist ABOVE-GROUND CHRLSTY,gpX ' <br /> COMPLETION ON <br /> SPECIAL PERMIT INFO. <br /> 1 proof <br /> Distance to sewer line <br /> Domestic well on site - Fy/ n) n' <br /> If yes, loca�n�on�and�d�stance <br /> ft. <br /> O <br /> C <br /> SAMPLING slatted <br /> — 8 <br /> Holding Temperature <br /> Method t <br /> Screening Method r =_ <br /> Tracking Sheet - (y/ n) ¢ _ <br /> q0 <br /> SPOILS <br /> Storage Method r do MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n' �},�, p <br /> Storage Location f Y l 51 Casing type <br /> Blank fr. Screen fr• <br /> Slot size <br /> GROUTING Bags cement q <br /> ( ',• Buckets bentonite I <br /> Depth to water o��vj �(� 7 Q��t r �� rn J1 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ <br /> Quantity Installed Discussed with geo st: - (y n) <br /> Type of method <br /> EH 29 29 <br />