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MONITORING WELL INSTALLATION REPOT.f <br /> Date: � 2 CONSTRUCTION <br /> Premise Address: !�"� ! ZZ� G�/ Total Depth <br /> /���� Screen Length (from) (to) <br /> Well No.: /"«l/' Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. <br /> Completion - Stove pipchristie box ircle one) <br /> Drilling Company: <br /> Driller: ---izz��� casing <br /> height <br /> Consultant 44> <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION C�iRISTY-$OX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Striacs <br /> 7 <br /> Distance to sewer line grout <br /> Domestic well on site -Gn ) 3 <br /> ft. <br /> If yes, location and distance - <br /> — a <br /> _ - m <br /> I — a <br /> SAMPLING dotted <br /> sat�on <br /> Holding Temperature tIV94 pack <br /> Method — <br /> Screening Method c <br /> Tracking Sheet - ( y/ n ) <br /> IF n <br /> SPOILS <br /> Storage Method MATERIALS/QEVELOPMENT <br /> Contamination Noted - (y/ n ) �_ <br /> Storage Location Casing type V <br /> Blankft. Screen /!7 • <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 />