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vMONITORING WELL INSTALLATION REPOi;T <br /> Date: �L CONSTRUCTION (� <br /> Premise Address: !4 a LTotal Depth l <br /> /L so r ww.n✓ Screen Length (from) U (to) �S <br /> Well No.: �� Filter Pack (from) L4 (to) <br /> Bentonite (from) L (to) 10 <br /> Inspector: Grout (from) (to) b <br /> Drilling rig type — <br /> Permit No. 5 30 Auger O.D. 11/1 I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: �j,� C— <br /> Driller: " / f a— 12-o,-1 casing <br /> Consultant C� <br /> 117 T height <br /> 7F <br /> Geologist ABOVE-GROUND <br /> CC WP L-Ef 1CN COMPLY-6CX <br /> COMPL E CN <br /> SPECIAL PERMIT INFO. Ground Surf ac <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) 36 ft. <br /> If yes, location and distance - ft. <br /> ft. a; <br /> _ c <br /> SAMPLING slotted _ ' c <br /> a G sacJon <br /> Holding Temperature —_ <br /> Method 9" P <br /> ack <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) = s <br /> n. IFn. <br /> SPOILS J <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) � <br /> Storage Location Casing type /max <br /> Blank d Screen ft. <br /> Slot size <br /> GROUTING [Bags cement <br /> Buckets bentonite 8 L <br /> Depth to water Bags sand/gravel <br /> Mix Ratios _ �-- I D-1 Z� � Filter Pack type/size .2-112- <br /> Installation <br /> l Z <br /> Installation Metho a Surge Block: - ( y� <br /> Quantity Installed Discussed with geologist: - ( y n ) <br /> EH 29 29 Type of method <br /> 3 o g 5- <br />