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MONITORING WELL INSTALLATION REPO <br /> Date: / '� " / CONSTRUCTION j <br /> Premise Address: �fP Total Depth / <br /> Screen Length (from) 76 (to) 6 <br /> Well No.: �S Filter Pack (from) _ (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. U/l Auger O.D. I.D. 5 <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: � <br /> Driller: casing _ <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE GROUND CHRZTY-BOX <br /> COMPLETION P <br /> SPECIAL PERMIT INFO. Ground 8urlaco <br /> Distance to sewer line grout <br /> Domestic well on site - ( / n 5� tt• <br /> If yes, location and distance - 8 tt <br /> (00 tt• <br /> _ <br /> = m <br /> — a <br /> SAMPLING slotted _ ?� <br /> Holding Tempiw�aatune "� = gave,P <br /> Method dtC o = <br /> Screening Method = <br /> Tracking Sheet ( y n ) <br /> 7 <br /> SPOILS C �y Q <br /> Storage Method J!Ze�Q I%C,46% MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( ED Vy h46 <br /> Storage Location Casing type <br /> Blank (O fr. Screen—Z ft. <br /> Slot size • <br /> GROUTING Bags cement T <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios 86-* /// -Y.- Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n <br /> Quantity Installed Discussed with geo ogist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />