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ONITORING WELL INSTALLATION REPO <br /> Date: I2[1-01/01 12/'Zth0 CONSTRUCTION <br /> Premise Address: 6(S- Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �T- Z_/e. 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: casing <br /> height <br /> Consultant <br /> Geologist <br /> ABOVE-GROUND <br /> COMPLETION CHRISTY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line 11W grout <br /> Domestic well on site - (y/n ) 3,U ft <br /> If yes, location and distance - '3 S <br /> ft. <br /> — a <br /> — m <br /> — e <br /> — c <br /> SAMPLING = ° <br /> glutted —_ c <br /> teC on — <br /> Holding Temperature <br /> Method <br /> Screening Method = <br /> : ? <br /> Tracking Sheet - (y/n) -# Mai <br /> ft. ft. <br /> SPOILS y <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) 2,w �t)L <br /> Storage Location Casing type <br /> Blankft. Screen /0 ft. <br /> Slot size 0•n 1 0 <br /> GROUTING Bags cement <br /> e� I Buckets bentonite <br /> Depth to water T Bags sand/gravel <br /> Mix Ratios Filter Pack type/size t'L <br /> Installation Method Surge Block: - (y/n <br /> Quantity Installed Discussed with geologist: - / n ) <br /> Type of method <br /> EH 29 29 <br />