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vIONITORING WELL INSTALLATION REPOni <br /> Date : S'/Z O - Q /J A CONSTRUCTION �+ <br /> Premise Address: 115pp30 0Total Depth 2O <br /> A f , Screen Length (from) Z (to) <br /> Well No. : Filter Pack (from) (to) <br /> Bentonite (from) (to) . <br /> Inspector: Grout (from) to) <br /> YJ �✓Zl� l y _ Drilling rig type <br /> Permit No. / rU !/ Auger O.D. I.D. <br /> Drilling Company: <br /> "Vdwa�f Completion - Stove pipe/christie box (circle one) <br /> Driller: f ' casing <br /> height <br /> Consultant (� � <br /> Geologist C dz�(i(�fK�' ._ T <br /> ABOVE•GRCUND CNAISTI'-BOX <br /> COWPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line 1sRRof0ut <br /> Domestic well on site - y n ) n <br /> If yes, location and distance - . �� Q ft <br /> (J (_ft. <br /> ` c <br /> SAMPLING = <br /> Blotted — c <br /> Qt - ax5an <br /> Holding Temperature f <br /> Method _ <br /> V" Pack <br /> Screening Method <br /> Tracking Sheet - ( y / n ) <br /> tt. IF ft. <br /> SPOILS <br /> Storage Method f G MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y n � „ <br /> Storage Location Casing type <br /> Blank ft. Screen LD ft. <br /> Slot size azz <br /> GROUTING Bags cement <br /> q Buckets bentonite ) w <br /> Depth to water = / Bags sand/gravel � <br /> Mix Ratios 7 •t 9 Filter Pack type//iize <br /> � 3 <br /> Installation Method Dar* Surge Block: . )( 5 <br /> Quantity Installed In E / Discussed with ggeeojoogist: - ( y <br /> Type of method <br /> EH 29 29 <br />