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MONITORING WELL INSTALLATION REPOnf <br /> �,_ _� Q,_ �3 �'3 ��� CONSTRUCTION <br /> Date: �T <br /> Premise Address: f Total Depth <br /> Screen Length (from) (to) <br /> Well No.: � Filter Pack (from) — 50 —(to)— <br /> Bentonite (from)-- (to) 5 <br /> Grout (from) 5 (to) <br /> Inspector: Drilling rig type <br /> Auger O.D. 19LD. <br /> Permit No. Completion - Stove pipe/christie box ( irde one) <br /> Drilling Company: <br /> casing <br /> Driller: height <br /> Consultant IryT <br /> � T <br /> Geologist � � ABOVF-GROUND �y-ty-gpX ' <br /> CCNFLETCN D <br /> Ground <br /> Surface <br /> SPECIAL PERMIT INFO. <br /> 50 °rte <br /> Distance to sewer line 5 <br /> n <br /> Domestic well on site - (y ft. <br /> If yes, location and distance - ft' <br /> 0 <br /> _ m <br /> c <br /> 0 <br /> SAMPLING dot nd _ B <br /> sac5on <br /> Holding Temperatureyh ° " 7'V91 P <br /> ack <br /> Method M =_ <br /> Screening Method <br /> Tracking Sheet - <br /> SPOILS <br /> Storage Method ti" � ME ��S/DEVELOPMENT <br /> Contamination Noted - (y n 'L <br /> Storage Location Casing type ft <br /> Blank U fr. Screen la <br /> Slot size 20 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Z Bags sand/gravel <br /> Depth to water Filter Pack type/size <br /> Mix Ratios 3U `'��' <br /> `T—Lor. Surge Block: - (y�n <br /> Installation Method <br /> Discussed with geologist: - ( y <br /> Quantity Installed <br /> Type of method <br /> EH 29 29 <br />