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MONITORING WELL INSTALLATION REPO <br /> Date: CONSTRUCTION <br /> Premise Address:— �-�( Total Depth A <br /> Screen Length (from) (to) <br /> Well No.: �� l Filter Pack (from) (to) <br /> Bentonite (from)_7 ! <br /> Inspector: Grout (from) (to) O <br /> Drilling rig type <br /> Permit No. d/C. �d � Auger O.D. V I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: � _ <br /> Driller 52� casing <br /> t 'T�n�j�ts.•r�C/G�� � height <br /> i <br /> ,i Consultant <br /> Geologist_��L <br /> + ABOVE-GROUND <br /> COMPLETION CORM TION <br /> COMPLETION <br /> a SPECIAL PERMIT INFO. Ground Suriact <br />" Distance to sewer line ? grout <br /> Domestic well on site - 01 nft. <br /> If yes, location and distance - <br /> Ift. <br /> q <br /> • C <br /> � O <br /> SAMPLING slotted e <br /> sacdon <br /> Holding Temperature — _ qn„W pack <br /> Method =_ <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS �5 <br /> Storage Method .155 MATERIALS/DEVELOPMENT <br /> Contamination Noted - Un ) / Y +t 5►G 1 ���',. <br /> Storage Location ,mat au� /tum Casing type 1� <br /> Blank ft. rr Screen--L-:5—ft- <br /> Slot <br /> creent-:5—ft-Slot size OZD <br /> GROUTING Bags cement <br /> _ Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios 3 Filter Pack type/size 3 <br /> Installation Method /�` �'' _ 49!dnj!!!td Surge Block: - (y <br /> Quantity Installed WY Discussed with geologist: - (y/(n: <br /> ) <br /> Type of method <br /> EH 29 29 <br />