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MONITORING WELL INSTALLATION REPOtZT <br /> Date: I � CONSTRUCTION <br /> Premise Address: 3 S L/6 Total Depth t d <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> (–� "� - Grout (from) (to) <br /> Inspector: <br /> Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: S � <br /> casing <br /> Driller: / ;Fheight <br /> �� t n��1 - <br /> Consultant ( ,.G � <br /> —EWT <br /> Geologist AiOVE-GRL`UND CHRZTY-BoX <br /> COMPLETION COMPLEncN <br /> SPECIAL PERMIT INFO. Ground Su•txs <br /> " prurt <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - ft• <br /> oC <br /> SAMPLING J% <br /> = 8 <br /> socicn — <br /> .~ <br /> Holding Temperature —_ <br /> Method <br /> Screening Method <br /> Tracking Sheet - (y/ n) <br /> ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type I (r) — <br /> Storage Location Blank Screen•__ fr• <br /> Slot size <br /> GROUTING Bags cement - <br /> I Buckets bentonite <br /> Depth to water ` D 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 />