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MONITORING WELL INSTALLATION REPOnf <br /> Date: /Z Z CONSTRUCTION <br /> Premise Address: <br /> ' /� Total Depth <br /> C' <br /> / Screen Length (from) (to)' <br /> Well No.: 7� P�5 Filter Pack (from) • (to) <br /> Bentonite (from)—(to)— <br /> Grout <br /> from) (to)Grout (from) (to) <br /> Inspector: Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: SSS <br /> Driller: � Z' casing <br /> height <br /> ConsultantW 47EW7F <br /> Geologist ABOVEGROUND CNfl13TY-BOX <br /> COMPLETION COMPLETICN <br /> SPECIAL PERMIT INFO. Ground Surface + — <br /> rA <br /> grout <br /> Distance to sewer line -76 <br /> Domestic well on site - (y/ n) tt• <br /> If yes, location and distance - 2 _—tt• <br /> 7 <br /> _ O <br /> C <br /> O <br /> SAMPLING slonad _ B <br /> taction —_ <br /> Holding Temperature 9n Pam <br /> Method = <br /> Screening Method = <br /> Tracking Sheet - (y/ n) (jam4. <br /> SPOILS <br /> Storage Method/ MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen <br /> Slot size <br /> GROUTING Bags cement <br /> .0 Buckets bentonite l <br /> Depth to water %✓�, Bags sand/gravel , <br /> Mix Ratios Filter Pack type/size I L <br /> Installation Method Surge Block: - (y/ n) <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> Type of method <br /> EH 29 29 <br />