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�- 1 <br /> rvl-ONITORING WELL INSTALLATION REPOM <br /> Date: 'o / /� CONSTRUCTION Q <br /> Premise Address: Total Depth / <br /> Screen Length (from) (to) <br /> Wel] No.: a/5 Filter Pack (from) (to) <br /> Bentonite (from) (to) 7b- <br /> Inspector: Grout (from):: <br /> from) b (to) O <br /> �LS Drilling rig typeE <br /> Permit No. rJ Auger O.D. g I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: u"' <br /> Driller: � 1 T /�,,//Ax /ate casing <br /> —T IffT <br /> height <br /> Consultant <br /> Geologist /✓LAG <br /> ABOVE-GROUND CtiA75?Y 80X <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground S <br /> Distance to sewer line ? grout <br /> Domestic well on site - (y/ n ) 76:S n• <br /> If yes, location and distance - n• <br /> Win. <br /> O <br /> SAMPLING dotted = <br /> &*tion = - <br /> Holding Temperature gravel Pads <br /> Method — <br /> Screening Method = <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method �t v ' "� MATERIALS/DEVELOPMENT <br /> Contamination Noted - (yp U <br /> Storage Location Casing type <br /> Blank ft. Screen---/d ft. <br /> Slot size .42-L0 <br /> GROUTING Bags cement '4 f <br /> r Buckets bentonite <br /> Depth to water "' .3 Bags sand/gravel <br /> Mix Ratios Filter Pack type/size Z 17 <br /> Installation Method w Surge Block: - (y/ n) <br /> Quantity Installed sSt 30s25 / S f 3D Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />