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MONITORING WELL INSTALLATION REPORT <br /> s 7 <br /> 4. <br /> CONSTRUCTION a <br /> Premise Address: J 7� Total Depth ' i <br /> Screen Length (from) -(to) ' <br /> Well No.: " (� Filter.Pack "(from) (to) <br /> Bentonite- '(from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. ID. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: , <br /> Driller: casing <br /> height <br /> Consultant <br /> /Q� <br /> - <br /> F <br /> — - T <br /> Geologist 7ll�t T <br /> ABOVE-GROUND <br /> COMPLETION 4 QF Rl"'i'Y-BOX <br /> COMPLETION <br /> SPECIAL.PERMIT INFO. Ground Surfao4 ..--�.. <br /> Distance to sewer line Groutti I <br /> j Domestic well on site - (y <br /> If yes, location and distance <br /> w <br /> h J 4 N 4 - <br /> '+-a k <br /> SAMPLING <br /> l Holding Temperature G. �. <br /> t4 ro prarel pack <br /> Method k <br /> Screening Method <br /> Tracking Sheet - (y/n ) /t • _.. <br /> P y <br /> SPOILS <br /> s <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) . <br /> Storage Location ` " Casing typeP�Ci <br /> x : <br /> C' Blank �— ft. Screen <br /> Slot size <br /> GROUTING 'fit. ,, :,. " ..9 ' Bags cement <br /> Buckets bentonite '~ ' <br /> Depth to water Bags sand/gravel,1A1, <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 r <br /> EH 29 29 <br />