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MONITORING WELL INSTALLATION REPORT <br /> Date: ` ` �" 1 CONSTRUCTION <br /> Premise Address: (4 Jbl Total Depth v <br /> ^ 1 Screen Length (from) E> (to) <br /> Well No.: Filter Pack (from) &0 (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to)±% _ <br /> Drilling rig type Lg� l.,v. �M <br /> Permit No. Auger O.D. I.D. <br /> Completion- Stove pipe/christie box (circle one) <br /> Drilling Company: J <br /> Driller. casing <br /> height <br /> Consultant IF) [I IL <br /> If <br /> Geologist' A---w V11 (-�!'1�l"�' — w In <br /> ABOVE-GROUND CHRiSiY-8OX <br /> CC&FL_ET',ON CJINPL=i iCN <br /> SPECIAL PERMIT INFO. Groucld Surf'c' <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) 7 <br /> If yes, location and distance - ' r D S <br /> m <br /> aA = <br /> o <br /> SAMPLING slotted <br /> a*csan <br /> Holding Temperature _ <br /> Method -AA, V+ti A-f' <br /> Screening Met-iod P i <br /> Tracking Sheet /n) \ <br /> M n <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - / n /-I- —2 " 7 C <br /> Storage Location sF,,, �, Casing type <br /> Blank ft. Screen fr <br /> Slot size <br /> GROUTING Bags cement <br /> r } / Buckets bentonite <br /> Depth to water '"T 5 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n) <br /> Quantity Insta�led Discussed with geologist. - (y/ n) <br /> Type of method <br /> EH 29 29 <br />