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MONITORING WELL INSTALLATION REPOts-f <br /> Date: -3 CONSTRUCTION t`'� �� J <br /> Premise Address: 3y"�tJ f Total Depth ! 5 T` r <br /> Screen Length (from) (to)_ _ <br /> Well No.: Filter Pack (from) (to) 1 2— <br /> Bentonite (from) Z (to) <br /> Inspector: Grout (from) 12 to <br /> / Drilling rig type /a <br /> Permit No. (D 3 Auger O.D. I.D. 33 <br /> Completion- Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist "' <br /> ABOVE-GROUND CHRZ Y4= <br /> OOt"PLETION cOMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> 5�i grout <br /> Distance to sewer line <br /> Domestic well on site - (y<D ft. <br /> If yes, location and distance - �/ ft. Z ft. <br /> p <br /> SAMPLING slotwd > <br /> saclon = <br /> Holding Temperature gmy1w Pack <br /> Method — <br /> Screening Method c = <br /> Tracking Sheet - (y/ n) <br /> �yi ft. F Lft. <br /> SPOILS <br /> Storage Method f MATERIALS/DEVELOPMENT <br /> . a <br /> Contamination N ted - ( 2.r dn- 4 <br /> Storage Location Casing type <br /> Blank 436 ft. Screen 5 R- <br /> Slot size O-oz� <br /> GROUTING Bags cement <br /> r Buckets bentonite_ " — 30 <br /> Depth to water r Bags sand/gravel '/t <br /> baj2 Mix Ratios Filter Pack type/size 3 <br /> Installation Me od Surge Block: - (y�ri� <br /> Quantity Installed Discussed with ge``o ogist: - (y <br /> Type of method <br /> EH 29 29 <br />