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R <br /> MONITORING WELL INSTALLATION REPf"T <br /> Date: CONSTRUCTIONe <br /> -77 <br /> Premise Address: Total Depth <br /> / / Screen Length (from) (to) <br /> Well No.: ��'�/!�`G`{ '�, Z, �� Filter Pack (from (to) <br /> Bentonite (fro ) (to) <br /> Inspector: Grout Ur ) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: Iqx <br /> Driller: casing <br /> / height <br /> Consultant n/Lc.G <br /> —q <br /> Geologist -- T <br /> ABOVE-GROUND <br /> COMPLEflON CNAiSTY-80X <br /> COMPLEMN <br /> SPECIAL PERMIT INFO. Ground Surfac* <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) 1 ft <br /> If yes, location and distance - <br /> ft• ft. <br /> SAMPLINGsocdon <br /> = s <br /> slottad c <br /> Holding Temperature <br /> VAYW <br /> Method = P <br /> ack <br /> Screening Method <br /> Tracking Sheet - Cy/ n ) <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 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 />