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371NITORING WELL INSTALLATION REPOh`+W <br /> Date: /�'Z�lj er <br /> CONSTRUCTION <br /> Premise Address: Total Depth s5 <br /> Screen Length (from) 5 S (to) 3 S <br /> Well No.: Filter Pack (from) 5 5 (to)� <br /> Bentonite (from) (to) '� o <br /> Grout (from) 3c> (to)— <br /> Inspector: <br /> Drilling rig type <br /> Auger O.D. $ I.D. <br /> Permit No. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> /w � 1 height <br /> Consultant <br /> _EWT <br /> Geologist l�`•""-� AgpyE•GRCUND <br /> COMPLETION C04mrpiY$OX <br /> COMPLETION <br /> SPECIAL PERMIT INFO. NW+ �Surface <br /> 7 W prart <br /> Distance to sewer line q �O <br /> Domestic well on site - (y n J <br /> If yes, location and distance - ft.n. <br /> — a <br /> SAMPLING slotted $ <br /> sac9on <br /> Holding Temperature oe- Lt = psl Packs <br /> Method _ <br /> Screening Method O <br /> Tracking Sheet - y�n ) <br /> SPOILS <br /> Storage Method MATEPJALS12EVELOPMENT <br /> Contamination Note (y/ n ) _ / 2" PVc— <br /> Storage Location M ^/� s" ��"` Casing type <br /> Blank JS" ft. Scr en fr• <br /> Slot size 01p n 1 <br /> GROUTING Bags cement z <br /> Buckets bentonite <br /> Depth to water // Bags sand/gravel �`Z <br /> Mix Ratios / t 0h'"Q V� Filter Pack type size12_ <br /> Installation Method 0` W Surge Block: - n ) <br /> Quantity Installed �'(L fkt Discussed with geologist: - y n ) <br /> —� Type of method <br /> EH 29 29 <br />