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r DNITORING WELL.INSTAL TION REPO. ! <br /> Date: y CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. i Z'� I.D. <br /> Drilling Company:.. UCompletion - Stove pipe/cluistie box (circle one) <br /> II�1n.R/lJ ,-., <br /> Driller: casing <br /> height <br /> Consultant ��i _._ <br /> Geologist T <br /> ABOVE-GROUND GiRtS7Y-BOX ' <br /> OOMPLEf�ON t: <br /> - } <br /> PECIAL PERMIT INFO. p=nd Sufac i COMPLETION , <br /> Distance to sewer line Ott # <br /> Domestic well on site - y n) <br /> If yes, location and distance <br /> J/ ', yql..- !♦' � .tom n <br /> SAMPLING o <br /> (/��, aacicn <br /> Holding Tem erature Y�`"l/ _ <br /> Method ` __ g"`w Pa <br /> Screening Method ` E"; <br /> Tracking Shcet y } �" _ <br /> �_...ft. .....�. ft. <br /> SPOILS l <br /> Storage Method ��¢u f Z MATERIALS/DEVELOPMENT <br /> Contamination Noted - y n ) <br /> Storage Location Casing type_IU C."C3 jK1 sjtp <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 -Z <br /> Installation Method-2a Surge Block: - ( y/ n ) <br /> Quantity Installed - Discussed with geologist: - / n) <br /> Type of mediod <br /> EH 29 29 <br />