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(tONITORING WELL INSTALLATION REP Y <br /> Date: //�c�`�I/Z� _ _ CONSTRUCTION <br /> PremisedA dress: � ✓lam- r Total Depth <br /> Screen Length (from) (to) <br /> Well No.: t#`3 Filter Pack (from) (to) <br /> - Bentonite (from) (to) <br /> Inspector: ' v( __ Grout (from) (to) <br /> -, Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> —�7 <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GRCUND CtiFi1STY-BOX `* <br /> GOf�LET101d COMPLE'nON - <br /> SPECIAL PERMIT INFO. Ground Surfwe „ <br /> Distance to sewer line �� h grout y A <br /> Domestic well on site - (y <br /> If yes, location and distance <br /> ft. <br /> ft. <br /> .v4 <br /> SAMPLINGslorod <br /> a <br /> socticn : <br /> Holding Temperature _ <br /> Method � � �' "�'� 72 pack, <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> .Y. <br /> :. ft. �.. "= _ ft. <br /> SPOILS l <br /> Storage Method 14MATERIM§MEVELOPMENT . <br /> Contamination Noted - {y/n <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTTNG Bags cement <br /> Buckets bentonite <br /> Depth to water �� Y Bags sand/gravel <br /> Mix Ratios _ a Filter Pack type/size <br /> Installation Method 7i19-1 Surge Block: - (y/ u ) <br /> Quantity Installed Discussed.with geologist. - (y/ n } <br /> Type of method <br /> EH 29 29 w <br />