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MONITORING WELL INSTALLATION REPORT <br /> Date: 1 CONSTRUCTION <br /> Premise Address: a L0Total Depth <br /> t ,, � Screen Length (from) ,5 O (to) b <br /> Well No.: `�v Filter Pack (from) 4ps (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (fro ) (to) <br /> !! � Drilling rig type Gu. <br /> Permit No. '13(��] Auger O.D. -1 <br /> Completion - Stove pipe/ tie bo (circle one) <br /> Drilling Compan <br /> Driller: t casing <br /> height <br /> Consultant I"— <br /> Geologist C�✓ <br /> �1 Q <br /> --��5� ABOVE-GROUND COMPLETION CHRSTY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Suria" <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/n) 1 C—S • ft. <br /> If yes, location and distance - <br /> sLft. ft. <br /> C <br /> SAMPLING <br /> slotted = o <br /> &action <br /> Holding Temperature = �v�W P <br /> ack <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> `y .= <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> 5. <br /> Contamination Noted - y n ) / / <br /> Storage Location Casing type U <br /> Blank ft. Screen ft. <br /> Slot size u <br /> GROUTING Bags cement <br /> Buckets bentonite <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 />