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1 wOAONITORING WELL INSTALLATION REP <br /> Date: ��� /17 _ CONSTRUCTION <br /> Premise Address: 6�' U k�u Total Depth <br /> Well No.: <br /> w 2- Screen Length (from) (to) <br /> _ Filter Pack (from) (to) <br /> p ff Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig e <br /> Permit No. Auger O.D. D" I.D. <br /> Completion - S ve pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> ��� height <br /> _EWT <br /> Consultant ��J <br /> Geologist % !/h'C 1.U.4 <br /> ABOVE-GROUND <br /> COMPLETION CHCOMRPLEIS'T1IONON <br /> SPECIAL PERMIT INFO. Ground Surixs <br /> Distance to sewer line 1.4� g grout <br /> Domestic well on site - (y r,Oft <br /> If yes, location and distance--: <br /> .. <br /> istance= _. <br /> h <br /> Me <br /> 0 <br /> SAMPLING elaru►d :r — <br /> �� asc;ion � <br /> G <br /> m _ <br /> Holding Teerature gImp Pack <br /> Method <br /> Screening Method ` <br /> Tracking Sheet n ) u, <br /> SPOILS <br /> Storage Method MA'[EWALS/D�EIVELOPMENT <br /> Contamination Noted - (y/ n } Casing type <br /> Storage Location Blank ft. Screen R• <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 />