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MONITORING WELL INSTALLATION R& _ ..T <br /> Date: Il����� CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.:_1?1G1� ,�/ T y jhGl/�� Filter Pack (from) (to) <br /> � Bentonite (from) (to) <br /> Inspector. !l��rl�I ��SS�"n� Grout (from) (to) <br /> _ Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: moi, <br /> Driller: -- //�1/� GZ�/�1�C�� casing <br /> r � height <br /> Consultant �C-�/'/� 'd <br /> Geologist /`'/�7�/�° ef/�/l �� -- •- <br /> W7:F <br /> ABOVE-GACUND <br /> COMPL�cT10N C�sSTY-80X <br /> COMPLE1CN <br /> SPECIAL PERMIT INFO. Ground Sumacs — <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - <br /> ft. ft. <br /> — m <br /> SAMPLING tlorvd — e <br /> saricn — <br /> Holding Temperature <br /> Method ' <br /> Screenin;Method .r, — <br /> Tracking Sheet - ( y/ n ) <br /> M <br /> SPOILS <br /> Storage Method MATERIALS/DEVEI.OPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> r Buckets bentonite <br /> Depth to water lJ Bags sand/gravel <br /> Mix Ratios_ Aall 11W 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 />