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.MONITORING WELL INSTALLATION REP(hnnf, <br /> . A <br /> Date: CONSTRUCTION <br /> Premise Address:O`o_J _ Total Depth <br /> AA � Screen Length from {to) <br /> Well No.: ��L/ y Filter Pack (from) (to) <br /> �J Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> ��6��F( Drilling rig e <br /> Permit No. Auger O.D. I.D. <br /> j- Completion -'Stove pipe/christie bo c (circle one) s <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consults ( 7 g w Y <br /> Geologist fl <br /> 1 •- <br /> ABOVE-GROUND , <br /> COWLETION CtiAtSTY-80X.i <br /> �..COMRL-E�ION <br /> SPECIAL PERMIT INFO. - n Ground Sudws ` <br /> Distance to sewer line - s -grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - h. <br /> ft. <br /> b` <br /> J � I <br /> / C <br /> SAMPLING G �� f vr�� :lotted <br /> a sac;ion <br /> Holding Te rature Y _ VIW Pack <br /> Method <br /> N <br /> Screening-Method <br /> Tracking Sheet - (y/n ) <br /> SPOILS <br /> Storage Method—J - _ MATERIALS/DEVELOPMENT <br /> + Contamination Not -�(�P/ n r, <br /> Storage Location • Casing type <br /> � <br /> Blank U ft. Screen fi <br /> Slot size 02� <br /> # GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water 57 Bags sand/gravel <br /> Mix Ratios " w�Filter Pack type/size <br /> Installation Method Surge Block: - ( y n l <br /> Quantity Installed �..' _ Discussed with ge gist: -;!V�n } <br /> _ . <br /> Type of metho <br /> EH 29 29d. <br /> t <br /> i , � <br />