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MONITORING WELL INSTALLATION REPOI'v <br /> Date: `�I�' �{I�i CONSTRUCTION <br /> Premise Address: INN t' ^ A Total Depth <br /> Screen Length (from) (to) <br /> Well No.: ?f7P'� Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: t Grout (from) 410 (to)2 <br /> Drilling rig type n.� � n <br /> Permit No. ��a'�3 1 Auger O.D. c�- 7-f I I.D. <br /> Q Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: �f S� <br /> Driller: casing <br /> T <br /> height <br /> Consultant�� <br /> Geologist <br /> ABCVE-GACUND CHRZTY-Box <br /> CCNFLETCN COMPLEMCN <br /> SPECIAL PERMIT INFO. Ground Surfacs <br /> Distance to sewer line <br /> Ott <br /> Domestic well on site - ( y/ nPA <br /> ) ft. <br /> If yes, location and distance - ft. <br /> ZIP—ft. <br /> 0 <br /> SAMPLING <br /> &C <br /> soden —' <br /> Holding Temperature — <br /> aCK <br /> Method V� 0,4 <br /> ' —_ Ravi F <br /> :t.. <br /> Screening Metho t <br /> C.: <br /> Tracking Sheet - y/ n ) <br /> SPOILS <br /> Storage Method N A MATERIALS/DEVELOPMENT <br /> Contamination Noted - / n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size •O Z v <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water�U Bags sand/gravel <br /> Mix Ratios h-� Filter Pack type/size <br /> Installation Method Surge Block: - ( y/ n ) <br /> Quantity Installed > O Discussed with geologist: - ( y/ n ) <br /> Type of metliod <br /> EH 29 29 <br />