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MONITORING WELL INSTALLATION REPOmf <br /> Date: r ZS�Qq�O� L CONSTRUCTION <br /> Premise Address: / ( C /`� � N Total Depth -�4" :72 LJ t = <br /> Screen Length (from)_ 3 <br /> Well No.: Filter Pack <br /> (from)Bento �q (� <br /> Inspector: Grout6nite (from) en r (tom <br /> (from) �o (to) y <br /> Drilling rig type_ BNi C— <br /> Permit No. Auger O.D. $ I.D. <br /> Drilling Company: <br /> OS/ Completion - Stove pipe/christie box (circle one) <br /> /� <br /> Driller: <br /> casing <br /> height <br /> Consultant <br /> Geologist _ T <br /> ABOVE-GROUND <br /> COMPLETION CNAiS1Y-BOX <br /> SPECIAL PERMIT INFO. Ground gu�f <br /> Distance to sewer line ✓W groL9 j <br /> Domestic well on site - (y/ n ) 56a a <br /> If yes, location and distance - ft. <br /> (09 <br /> ft• <br /> (O r 0 ft. 6 tL <br /> — - m <br /> = o <br /> = m <br /> SAMPLING _ <br /> slotted — 'c <br /> sacion — <br /> Holding Temperature <br /> Method = VA °I Pack <br /> Screening Method <br /> Tracking Sheet - (y/ n ) I <br /> 72 <br /> SPOILS ��N➢ <br /> t <br /> 7Z �y <br /> Storage Method ^•� rc M_ ATERIALS/QEVELOPMENT <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 /> EH 29 29 Type of method <br />