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N _ IONITORING WELL INSTILLATION REPCIDT <br /> Date : � U/ Z 0� /' / _ q ' CONSTRUCTION <br /> Premis Ae ddress: 5? .r 94004 i� '"� y Total Depth <br /> ' / Screen Length (from) Cto) <br /> Well No. : / W /I 21 YI ✓ 1 (2Af 46 Filter Pack (from) (To) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. LD. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> casing <br /> /� l—� height <br /> Consultant l �bS lam' <br /> Geologists p ggpyE GROUND <br /> COMPLETION CN <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground 8 Race <br /> Distance to sewer line grout <br /> Domestic well on site - ( y / n ) ft, <br /> If yes, location and distance - g, <br /> ft. <br /> SAMPLING slotted <br /> aecIon a — <br /> Holding Temperature gravel pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ ri =_ <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 /> VA / Buckets bentonite <br /> Depth to water w 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 />