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1 <br /> MONITORING WELL I STALLATION REPORT <br /> `Date: I CONSTRUCTION <br /> Premise Address. j1 U_j ^ l- Total Depth <br /> ' Screen Length (from) (to) <br /> W o.: Filter-Pack (from) (to) <br /> Bentonite (from} (to) <br /> t Inspector; I Grout (from) (to) <br /> ` Drilling rig type <br /> Permit No. Auger O.D. ,- LD. <br /> i Completion.- Stove pipe/chrisde box (circle one) <br /> Drilling Company: <br /> . . { '� t"�� c it ,, r . . � �' ' .� .� .HS.,� •.��` I <br /> Driller: casing <br /> ,E height ' <br /> ConsultantA _ - <br /> I � <br /> Geologist + •+ ; }w r # �* t ' •- <br /> ABOVE-GROUND <br /> CO W L ETION # CHRISN40X " <br /> COMPLETION <br /> SPECIAL PERMIT INFO. G=nd Surface ...... <br /> grout ts, <br /> Distance to sewer line i s <br /> Domestic well on site - (y/ n <br /> If yes,location and distance - v <br /> V .#' <br /> ""1 C <br /> SAMPLING slatted ws = <br /> aacdon <br /> [� <br /> Holding Temperature 7 L . gmVel Pack <br /> — L <br /> Method : •� <br /> Screening Method <br /> Tracking Sheet - (y/n <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> I Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mist Ratios i 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 />