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MONITORING WELL INSTALLATION DEPORT <br /> Date:bIA3 CONSTRUCTION <br /> Premise Address: -el 1r�/ �� L�'�'Ly WSJ Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D.101n 16- I.D. <br /> Drilling Company:_ <br /> C/ Completion - Stove pipe/christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist .. T <br /> ABOVE-GROUND <br /> COMPLETION CNAIST 4= <br /> COMPLETION <br /> SPECIAL PERMIT INFO. pend Sumacs <br /> Distance to sewer line Grp <br /> Domestic well on site - (y/ n ) ft <br /> If yes, location and distance - <br /> . ft. <br /> ft. <br /> A <br /> C <br /> SAMPLING — <br /> aloud c <br /> sacton '— <br /> Holding Temperature _ <br /> Method = vs"w P� <br /> Screening Method <br /> Tracking Sheet - (y/ n ) _ <br /> h. "= = 1 Fft. <br /> SPOILS <br /> Storage Method MATERIALS/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`'V 5- , hi r. Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />