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ONITORING WELL INSTALLATION REP* <br /> Date: C"/ <br /> ? CONSTRUCTION <br /> Premise Address: ` �� 5 �� Total Depth r7 f _ <br /> Screen Length (from) f='T� (to) <br /> Well No.: /,/ - Filter Pack (from) (to) <br /> Inspector: S Bentonite (from)_ c�sf (to) <br /> . Grout (from) 4t•i i (to) <br /> Drilling rig type <br /> Permit No._ �> � Auger O.D. I.D. <br /> Drilling Company:— / Completion - Stove pipe/clu-istie box (circle one) <br /> nom% `//�-�ci <br /> casing <br /> Consultant height��� '4 <br /> Geologist <br /> ABOVE-GRCUND <br /> COWLE ION CHR*7Y-8OX <br /> SPECIAL PERMIT INFO. Ground Su facs COMPL.�'T1CN <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) `-`7 ft. <br /> If yes, location and distance - <br /> �ft. ft. <br /> `ti. -a <br /> o <br /> SAMPLING clot:" v <br /> aoc2cn <br /> Holding Temperature C <br /> Method ` — <br /> Screenin;Method <br /> Tracking Sheety n ) <br /> I rJ ft. <br /> SPOILS <br /> Storage Method _57.75�_ S MATERIALS/DEVELOPMENT <br /> Contamination Noted - <br /> Storage Location_ C--V'? ✓�fC�_ Casing type <br /> Blank �_- ft. Screen /J- ft• <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water <br /> Bags sand/gravel <br /> Mix Ratios (/ ;, Filter Pack type/size <br /> Installation Method Surge Block: <br /> Quantity Installed Discussed with geologist: �T- <br /> j n ) <br /> EH 29 29 Type of method <br />