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MONITORING WELL INSTALLATION REPOn0 <br /> Date: l' T CONSTRUCTION <br /> Premise Address: �A ' � /(Nl/ '�` Total Depth <br /> Screen Length (from) (to) G <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) 19.Z- <br /> Inspector: <br /> ZInspector: Grout (from) Z (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. 9- I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: t w <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist C " - T <br /> ABOVE-GROUND (iii <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surlace <br /> Distance to sewer line < afout <br /> Domestic well on site - ( y/ n ) S <br /> If yes, location and distance - ft <br /> _ <br /> — a <br /> c <br /> SAMPLING slcttad _ 8 <br /> taction <br /> Holding Temperature = gn P <br /> Method = <br /> ack <br /> Screening Method <br /> C: <br /> Tracking Sheet - (y/ n ) <br /> SPOILSa <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ n ) r ✓C <br /> Storage Location Casing type <br /> Blank__S& ft. Screen ft. <br /> Slot size a <br /> GROUTING Bags cement i <br /> Buckets bentonite Z <br /> Depth to water �/ Bags sand/gravel 3 <br /> Mix Ratios Filter Pack type/size Zvi <br /> Installation Method Surge Block: - ( / n <br /> Quantity Installed Discussed with ge gist: - (yO <br /> Type of method <br /> EH 29 29 <br />