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MONITORING WELL INSTALLATION REPOr�f <br /> Date: ��� CONSTRUCTION / <br /> Premise Address: lt� - Total Depth <br /> Screen Length (from) S (to) l <br /> Well No.: 7i Filter Pack (from) Zi (to)� <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (o (to) O <br /> /�� Drilling rig type <br /> Permit No. � 357 3 O Auger O.D. I.D. <br /> // �� Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: /r1 <br /> Driller: n <br /> casing <br /> —Av— height <br /> Consultant <br /> GeologistL� <br /> ABOVE-GROUND <br /> CHRS7Y4= <br /> COWFLEfION OMC <br /> SPECIAL PERMIT INFO. Ground Sul. <br /> proof <br /> Distance to sewer line l <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - ft. <br /> /b ft• _ <br /> O <br /> I m <br /> r <br /> O <br /> SAMPLING slortad = <br /> sacdon — � <br /> Holding Temperature Gnvs�Pa <br /> Method = <br /> Screening Method : _ <br /> Tracking Sheet n ) <br /> SPOILS <br /> Storage Method 55 /��"'"' S MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) , I C <br /> Storage Location QA.5-c Casing type <br /> g `-' Blank I ft. Screen <br /> Slot size - <br /> GROUTING Bags cement <br /> Buckets bentonite N ria <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 />