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MONITORING WELL INSTALLATION REP,r' <br /> Date: 2:!Z06 <br /> A <br /> ,fid D6 CONSTRUCTION <br /> J <br /> Premise Address: 21 W` l�u�d s Total Depth / Z <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> :11(2 Completion - Stove ipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: k casing <br /> height <br /> Consultantp T <br /> Geologist T <br /> ABOVE-GROUND r Ci�FiIST'Y-BOX <br /> COMPLETION / COMPLETION <br /> SPECIAL PERMIT INFO. Orcurd Suiacr T <br /> i <br /> Distance to sewer line &" gf01n <br /> Domestic well on site - (y/ n) <br /> ft. <br /> If yes, location and distance - <br /> ft ft. <br /> q <br /> O <br /> a• — c <br /> o <br /> SAMPLING slottad = -E <br /> D( ascson <br /> Holding Tem erature ��J fPspaCk <br /> Method c&,M <br /> Screening Metho7., <br /> Tracking Sheet - y n) <br /> tt. = ft. <br /> SPOILS <br /> Storage Method N/A MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> ( Buckets bentonite <br /> Depth to water N ["�0 Bags sand/gravel <br /> Mix Ratios _ Filter Pack typ�/size <br /> Installation Method _x_41- QL— Surge Block: (y/ n ) <br /> Quantity Installed' i / Discussed wth geologist: - (y/ n ) <br /> Type of m od <br /> EH 29 29 <br />