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�-WVIONITORING WELL INSTALLATION REP <br /> Date: S CONSTRUCTION q <br /> Premise Address: T�' Total Depth__ <br /> Well No.: Lc) S Screen Length (from) RS ;�(to)— <br /> Filter Pack (from) G (to) <br /> 1,�n/� <br /> Bentonite (from) /03 (to)� <br /> Inspector-" Grout (fro ) (to) <br /> Permit No. n b , I-7 S0 Drilling rig type (t o A- a it s <br /> Auger O.D. 1 O I.D. <br /> Drilling Company: 9 � Completion - Stove pipe/qts (circle one) <br /> j <br /> tie o c <br /> Driller: � _— casing <br /> height <br /> Consultant Lj�ti Y 1 X T <br /> GeologistLvts —QW <br /> ABOVE-GROUND <br /> COMPLETION CHAISTY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. around Sufacs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n <br /> If yes, location and distance ft. <br /> O <br /> = 0 <br /> C <br /> SAMPLING slotted = B <br /> �\ sectlon <br /> Holding Temperature ) <br /> ack <br /> Method _ VaLD <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS — <br /> Storage Method ty�� I I � XJrM MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) (/ r {p J <br /> Storage Location Casing type 'f 1 <br /> Blank (o S ft. Screen --Z ft. <br /> Slot size D a <br /> GROUTING Bags cement <br /> ( Buckets bentonite---/ <br /> Depth to water_ ID Bags sand/gravel <br /> Mix Ratios Filter Pack type/size 12- <br /> Installation Method n v wC a on Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 r <br />