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7NITORING WELL INSTALLATION REPO` <br /> Date: ')4 _ CONSTRUCTION <br /> Premise Address: 1/N0 L/• "�``��" L- Total Depth <br /> Screen Length (from) (to) <br /> Mt <br /> Well No.: / V &:Pu S ��"�,1, �� �0 Filter Pack (from) (to) <br /> �- Bentonite (from) (to) <br /> Inspector: L� ���. 0 _ 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 /> casing <br /> Driller: --- - height <br /> Consultant — <br /> I / <br /> ABOVE-GROUND C44R;STY-80X <br /> CCN,PL� ION COMPLETICN <br /> SPECIAL PERMIT INFO. mrd SLeaca <br /> proc.K <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) * ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> = a <br /> L <br /> - C <br /> O <br /> SAMPLING dotted <br /> soon � <br /> Holding Temperature <br /> Method ! — <br /> Screening Method <br /> Tracking Sheet ( y/ n ) <br /> LL <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 /> Buckets bentonite <br /> Depth to water ����S l _ 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 />