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Z..NITORING WELL INSTALLATION REP <br /> Date: 1 �� CONSTRUCTION f <br /> Premise Address: it S'G(� Total Depth Z21 <br /> / Screen Length (from) l (to) Z ' <br /> Well No.: 061 Filter Pack (from) 17 –(to)� <br /> Bentonite (from) (to) / <br /> Inspector: Grout (from)_ / (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: cas ing <br /> heightConsultant <br /> _qV_f <br /> Geologist <br /> ABOVE-GROUND C4-MM-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Geiound Surf <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) ft. <br /> Ifyes, location and distance - <br /> �• ft. <br /> vh m <br /> 9.c e <br /> yn � <br /> "'l C <br /> SAMPLINGtocOon <br /> = <br /> tiottod w; — � <br /> Holding Temperature <br /> Method — WA�Pack <br /> Screening Method — <br /> Tracking Sheet - (y/n ) ' <br /> �l <br /> SPOILS F 1d yt�v <br /> Storage Method MATERIALS/DEVELOPMENT_ _ <br /> Contamination Noted - (y/ n } <br /> Storage Location Casing type <br /> Blank ft. Screen fC. <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 />