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MONITORING WELL INSTALLATION REPORwp,,' <br /> Date:- CONSTRUCa � <br /> TION � <br /> Premise Address: `x `�`J UjWTotal Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) S (to) <br /> Bentonite (from) (to) 2. <br /> Inspector. {. Grout (from) 2S . (to) <br /> / Drilling rig type <br /> Permit No. �� C Auger O.D. U I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Campany: .� <br /> Driller: casing <br /> 177T <br /> height —QW7:F <br /> :Ologist <br /> nsultant <br /> ��� � V_I <br /> ABOVE-GROUND CHRZ'rY-SOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface t� <br /> Distance to sewer liney grout `2 • J <br /> Domestic well on site - (y y <br /> � V <br /> If yes, location and distance - J - <br /> ft. <br /> ft. <br /> SAMPLING <br /> Holding Temperature <br /> Method ' = Sxa�Pack <br /> >, <br /> ScreeningMethod <br /> Tracking Sheet - y//n ) <br /> ft. V M <br /> SPOILS <br /> Storage Method TV�- – MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( `'/ n )g+.(-7f /C C <br /> Storage Location Casing type f — <br /> Blank Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite / L <br /> Depth to water Bags sand/gravel —r <br /> Mix Ratios Filter Pack typ. e M <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with ogist: - t y n ) <br /> Type of method <br /> EH 29 29 <br />