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—..'ONITORING WELL INSTALLA'T'ION REP6.,. <br /> Date: f J ` CONSTRUCTION <br /> Premise Address: �2(� ��I k Gv' N" !\ `� oL'i Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �� Filter Pack (from) (to) <br /> ` Bentonite (from) (to) <br /> Inspector: N C � Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> 7 Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: -t., <br /> Driller: Ton n U 65-z,, Tcasing <br /> 1_ T height <br /> Consultant AC� IV <br /> Geologist � �C •-' <br /> ABOVE-GAGWND CHRtSTY-Box <br /> CONFLETION COMPLEMN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> Qrcut <br /> Domestic well on site - ( y/ n ) .ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> ..a p <br /> SAMPLING <br /> at\./Cin R� <br /> ��.r� wM �/ <br /> Holding Temperature _ <br /> Method -' = VSVW pack <br /> �.: <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) —' <br /> '.x <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing 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 />