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—MONITORING WELL INSTALLATION REP(Ki <br /> Date: CONSTRUCTION <br /> Premise Address: I`I�Vj Lfl� Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> _ pn Bentonite (from) (to) <br /> Inspector: ^r1C Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant ' <br /> r7T <br /> Geologist —7T <br /> ABOVE-GROUND <br /> COMPLETION CHSZTY43OX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surf act <br /> Distance to sewer line grout <br /> Domestic well on site - ( y/ n ) ft <br /> If yes, location and distance - <br /> ft. <br /> ft. <br /> SAMPLING = <br /> slotted — c <br /> saction <br /> Holding Temperature <br /> Method — grs�pack <br /> Screening Method g- <br /> Tracking Sheet - ( y/ n ) — <br /> ft. — IFft. <br /> SPOILS <br /> Storage Method M_ ATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Z 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 />