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,MONITORING WELL INSTALIAMON REP ' <br /> Date: ` CONSTRUCTION <br /> Premise Address: �37 LA-2, 1te , Srk V Total Depth <br /> (, Screen Length (from) - (to) <br /> Well No.: A w1- (d Awl-, P [4er ld Filter Pack (from) - (to) <br /> Bentonite (from) (to) <br /> Inspector: Lj Grout (from) (to) <br /> Drilling rig tYPe <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> l height <br /> Consultant �`'�� 'T <br /> —qVT <br /> �d <br /> Geolo6t � ABOVE-GROUND <br /> CCHRSSiY-80X <br /> COMPLETION <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ft, <br /> � C <br /> C <br /> SAMPLING slatted y: <br /> �. <br /> soon — <br /> Holding Temperature = ver <br /> _ Va Pack <br /> Method <br /> Screening Method ; <br /> Tracking Sheet - (y/ n ) _ <br /> fL - tL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location ming type <br /> Blank ft. Screen ft. <br /> Slot size <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 /> 360- V 7-7,V// Zov-7 <br />