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MONITORING WELL INSTALLATION REPORT <br /> bp) 111A <br /> Date: l er ( o g CONSTRUCTION <br /> Premise Address: 5731 Total Depth <br /> �^ D Screen Length (from) (to) <br /> Well No.: lJ�O 1 r 'N' w Filter Pack (from) (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/clu-istie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GRMND <br /> COMPLETION CHAISTY-80X <br /> COMPLEMN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line Oren <br /> Domestic well on site - (y/ n ) ft. <br /> If yes, location and distance - <br /> • ft- <br /> 4" m <br /> c <br /> SAMPLING _ <br /> Mora•! :.: — c <br /> &mien <br /> Holding Temperature _ F <br /> Method = _ <br /> Screening Method — <br /> Tracking Sheet - ( y/ n ) r` _ <br /> ft. - ir <br /> ------ ft. <br /> SPOILS <br /> Storage Method MATEMALS/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 J `J Bags sand/gravel <br /> Mix Ratios /V�--t _ U Filter Pack type/size <br /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Vn Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />