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• • <br /> MONITORING WELL INSTALLATION REPORT <br /> Date:Z /��� CONSTRUCTION <br /> Premise Address: 37�i�' �✓L Y oC Total Depth I i ((tXG <br /> Screen Length (from) (to) <br /> Well No.: 5(�O I Filter Pack (from) (to) <br /> 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 /> uG^ height <br /> Consultant Y� � " <br /> Geologists ' <br /> IN M <br /> ABOVE-GROUND —EWT <br /> COMPLETIONsal CHRISTY-BOX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. Ground Sulxw <br /> Distance to sewer line 1� grout <br /> Domestic well on site - (y ft <br /> if yes, location and distance - <br /> ft, ft. <br /> — m <br /> p <br /> O <br /> C <br /> SAMPLING slottod _ c <br /> section <br /> Holding Temperature <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/n ) a <br /> SPOILS <br /> Storage Method MATERIALS E LOPMENT <br /> Contamination Noted - ( y/ n ) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size_/ <br /> GROUTING Bags cemenf <br /> Buckets bentonite <br /> Depth to water •% Bags sand gravel <br /> Mix Ratios ( Filter Pack type/size <br /> Installation Metho Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: - ( y/ n ) <br /> Type of method <br /> EH 29 29 <br />