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"MONITORING WELL INSTALLATION REPOnC <br /> Date: IL2- S—lo 7- CONSTRUCTION <br /> Premise Address: 10o6) C/ Total Depth <br /> S./� r t C Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> 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: casing <br /> height <br /> Consultant <br /> Geologist •- <br /> ABOVE-GiiCUND C1iA757Y 80X <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line RE, grout <br /> Domestic well on site - (y/ n ) 4 g <br /> ft. <br /> If yes, location and distance - _ <br /> 55 ft, 5172- ft. <br /> _ <br /> t O <br /> SAMPLING slatted = G. <br /> sactcn <br /> Holding Temperaturegmys= Pack <br /> Method = <br /> Screening Method c <br /> Tracking Sheet - ( y/ n ) <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 II '' <br /> LAS -U7 <br />