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�- AONITORING WELL INSTALLATION REP('—h <br /> Date: 1 ^s:S <br /> . CONSTRUCTION <br /> Premise Address: SS � \,� 1Total Depth <br /> s r <br /> rnI Screen Length <br /> (from)—'X—ST (t <br /> Well No.: Filter Pack (from) 5 i (to) 3 j— <br /> Bentonite (from) (a? (to) 6 / <br /> Inspector: Grout (from) 1 (to)� <br /> Drilling rig type <br /> Permit No. 0b 5 S Auger O.D. <br /> Completion - Stove pip christie box (circle one) <br /> Drilling Company: <br /> Driller: CJ casing <br /> height <br /> Consultant y �� l l 1 \ <br /> Geologist — \ h�✓� 1 <br /> ABOVE-GROUND CHR*rY-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surtan <br /> Distance to sewer line � grout <br /> Domestic well on site - (y"� � 1 ft. <br /> If yes, location and distance - ft. <br /> = d <br /> _ o <br /> SAMPLING slotted <br /> wcaon 'F <br /> Holding Temperature P� gravel p <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n ) �v 4' <br /> 5ft. <br /> SPOILS <br /> Storage Method "` 1 '" MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y <br /> Storage Location Casing type <br /> Blank ft. Screen <br /> Slot size b 2 <br /> GROUTING Bags cement <br /> n Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size Y R ✓ L �iriz <br /> Installation Method Surge Block: - (y/ t <br /> Quantity Installed Discussed with geologist: -/(�/ n ) <br /> Type of method <br /> EH 29 29 <br />