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- ONITORING WELL INSTALLATION REPO <br /> Date: .2-3 `D, CONSTRUCTION <br /> Premise Address: . L%h t.D r\ Total Depth <br /> - - - Screen Length (from) (to) <br /> Well No.: l a- Filter Pack (from) 73 (to) <br /> - - Bentonite (from)- (o el (to) 73 <br /> Inspector: 11 Grout (from) rec. (to) 9 <br /> Drilling rig <br /> type <br /> Permit No. Auger O.D. I.D. <br /> I- ) Completion -Stove pipe/ (circle on <br /> Drilling Company: ��1 ct'rIQ U <br /> Driller: casing <br /> {� height - <br /> Consultant <br /> Geologist--- �_ � L h t"l b-{'\ <br /> ABOVE-GROUND <br /> COMPLETION C_HSZTY-80X <br /> COMPLETION <br /> SPECIAL PERMIT INFO. _ _ _. _ - around Sur{ <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) ft <br /> If yes, location and distance - <br /> — m <br /> SAMPLING <br /> slottad — <br /> sac5on — <br /> Holding Temperature —` <br /> .: <br /> gravelgravePackP <br /> Method — <br /> Screening Method - <br />_. Tracking Sheet - (y/ n) _ <br /> SPOILS _ <br /> Storage Method _ MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> jp v <br /> type - <br /> Storage Location Casing <br /> a <br /> Blank -13- ft. Screen 11) ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installas.itm Method Surge Block: - (,:,, n ) <br /> Installed Discussed with geologisL': - (y/ n ) <br /> Type of method_.. <br /> EH 29 29 _ <br /> ' a <br />