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r a llriiiJNITORING WELL INSTALLATION REPOIJ <br /> Date: 1 CONSTRUCTION <br /> Premise Address:_ Total Depth -P0 <br /> i Screen Length (from) (to) 1 <br /> Well No.: ryl Filter Pack ([xom) 12--b _(to)� <br /> , r Bentonite (from) (to) <br /> Inspector. , �VLf � _ Grout (from) <br /> r v Drilling rig type <br /> Permit No. Auger O,D. I.D. <br /> i Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> r _ <br /> ITheight <br /> Consultant (�' <br /> 71 <br /> Geologist �- T <br /> ABOVE-GRCUND CNAtSTY-80X <br /> cOMPLETION cOMPLEnoN <br /> SPECIAL PERMIT INFO. - Grourd S+.dwe <br /> Distance to sewer line groan <br /> Domestic well on site - {y/ n <br /> If yes, location and distance - . <br /> " V <br /> SAMPLING q slored v <br /> Holding Temperature t/L°� sac�on "_ �Pack <br /> Method K " <br />{ Screening Meth d Yt o1--X <br /> Tracking Sheet - (y/ n ) <br /> a.�...-...tt. % <br /> f SPOILS „ <br /> t <br /> Storage Methods MATERIALS/DEVELOPMENT <br /> Contamination NoteLa@:� ELStorage LocatioaaCasing type_ _ <br /> Blank ft. Screen ft. <br /> „ Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water "l r L Bags sand/gravel <br /> Mix Ratios l Filter Pack type/size <br /> Installation Method Surge Block: - (y <br /> 3 Quantity Installed W Discussed with geologist: - jy/ n) <br /> Type of method <br /> EH 29 29 <br />