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l <br /> L-eAONITORING WELL INSTALLATION REP � <br /> Date: /� 1 CONSTRUCTION <br /> Premise Address: .R/o � f.,-.-�� yu�f Total Depth <br /> b C . A�}� Screen Length (from) (to) <br /> Well No,: Filter Pack (from) (to) <br /> }} Bentonite (from) (to) <br /> Inspector- 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 /> Driller: l'�� � .. _ casing <br /> _ height <br /> Consultant--:/— '4 <br /> J� <br /> Geologist z l t'C Leh k <br /> ABOVE-GRCUND CHMM-8CX <br /> COMPLETION COMPLETi N <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - <br /> ft. ft. <br /> SAMPLING accred = c <br /> seders <br /> Holding Temperature r — <br /> Method = g' <br /> Screenin;Method <br /> Tracking Sheet - (y/ n ) <br /> r — <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type <br /> Blank ft. Screen 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 /> Installation Method Surge Block: - (y/ n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />