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-i'vtONITORING WELL INSTALLATION REPOnT <br /> Date: ��rT O7� F� CONSTRUCTION��77 <br /> Premise Address: �YQ� Total Depth - 5 <br /> Well No.: <br /> L Screen Length (from) (to) <br /> Filter Pack (from) (to) <br /> Bentonite (from) /.G (to) <br /> Inspector: <br /> Grout (from) (to) <br /> Permit No. JIJ�s�ri Drilling rig type <br /> Auger C.D. R' I.D. <br /> Drilling Company: <br /> p �� Completion - Stove pipe/christie box (circle one) <br /> ,u- 0 <br /> Driller:_ �/ / ,ri1 <br /> casing <br /> G <br /> Consultant height <br /> Geologist / <br /> ABOVEGROUND <br /> COMPLETION CHRM Y-9OX <br /> SPECIAL PERMIT INFO. GCOMPLETION <br /> Ground Suri <br /> Distance to sewer line ? grout <br /> Domestic well on site - (y/n ) <br /> If yes, location and distance - ft. <br /> �/� ft. <br /> TY: <br /> V � 0 <br /> O <br /> 1' O <br /> SAMPLING slonnd = o <br /> Holding Temperature /y sactlan <br /> Method = Or+vw Pack <br /> Screening Method _ :'• <br /> Tracking Sheet - (y/n ) <br /> tt• — tt <br /> SPOILS <br /> Storage Method 4ul MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n �r ✓e <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> GROUTING Slot size /O <br /> Bags cement .y <br /> d Buckets bent ite — - G <br /> Depth to water Bags sand/ 1. <br /> Mix Ratios_ Pse.L t d Filter Pack type/size i <br /> Installation Method Surge Block: - (y/ n) <br /> Quantity Installed U Discussed with geologist: - (y/n) <br /> EH 29 29 Type of method <br /> Z- A-V <br />