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PONITORING WELL INSTALLATION REPOrP <br /> Date: G CONSTRUCTION <br /> Premise Address: / E)a(7 � �/J lvLtJr!/ Total Depth t(/b <br /> Well No.: ' ?i Screen Len:type <br /> from) (to) <br /> Filter Packrom) (to) <br /> Bentonitefrom) (to) <br /> Inspector: Grout rom) (to) <br /> Permit No. a/� Drilling rig S <br /> Auger O.D. I.D. <br /> any: <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Com <br /> Driller: <br /> casing <br /> height <br /> Consultant <br /> Geologist T <br /> ABOVE-GROUND <br /> CONFLETION CHRISTY-BOX <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line �D grout <br /> Domestic well on site - (y n <br /> If yes, location and distance - 6-3 ft. <br /> ft. ft. <br /> _ m <br /> = o <br /> = m <br /> SAMPLING _ o <br /> tlotUdtecdon <br /> Holding Temp a 64 <br /> Method gRyal Pack <br /> Screening Method <br /> Tracking Sheet - n ) <br /> 'o ft. <br /> SPOILS <br /> Storage Method_ 1� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n 7 �/ <br /> Storage Location Q � "44 Casing type <br /> ll Blank fEt fr. Screen ft. <br /> Slot size ,0/0 " <br /> GROUTING Bags cement t <br /> Buckets bentonite ykclAx <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 /> I;All6 <br />