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MONITORING WELL INSTALLATION REPOnP <br /> Date: o lffl(s( 2�� CONSTRUCTION <br /> Premise Address: (��) Total Depth <br /> Screen Length (from)—(to)- <br /> Well <br /> from) (to)Well No.: 'T� Filter Pack (from)—(to)- <br /> Bentonite <br /> from) (to)Bentonite (from)—(to)- <br /> Inspector: <br /> from) (to)Inspector: Grout (from)_(to)- <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> / Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: "-7�r% casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND CNRtM43OX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground SuArs <br /> Distance to sewer line P <br /> grout <br /> Domestic well on site - ( y/ n ) l tt <br /> If yes, location and distance - tt <br /> 5Z n. <br /> 26° <br /> A = m <br /> Gl.sm <br /> SAMPLING 65 slotted <br /> y sadon � <br /> Holding Temperature pack <br /> Method = <br /> Screening Method �' r <br /> Tracking Sheet - ( y/ n ) r __ <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <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 /> Type of method <br /> EH 29 29 <br /> " Z -7— �� ,�5 4/7 �d <br />