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y„JNITORING WELL INSTALLATION REPO <br /> Date: �- 1l CONSTRUCTION <br /> i 1 <br /> Premise Address: O W � Total Depth d <br /> Screen Length (from) '�5 ___ (to) D a' <br /> Well No.: {� ( Filter Pack (from) –(to)— 00 <br /> Bentonite (from} �D r (to) ' r �— <br /> Inspector. Grout (from O ' (to) <br /> Drilling rig type <br /> Permit No. SS Auger O.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller casing <br /> height <br /> Consultant 7/4 " 7F <br /> Geologist <br /> ABOVE-GROUND toitN4 <br /> CONFLETCN <br /> SPECIAL PEmanddi <br /> Ground Sudacs <br /> proofDistance toDomestic wIC) ft. <br /> If yes, locatie - <br /> a <br /> a r. • <br /> — C <br /> SAMPLING brad yr C <br /> sadcn <br /> 3 <br /> Holding TemperaturePack <br /> Method `r <br /> Screening Method i <br /> Tracking Sheet - {y/ n) - <br /> - <br /> n <br /> SPOILS <br /> Storage Method .. , s.� MATERIALS/DEVEI.OPMENT <br /> Contamination Notid. - (y/ n) TZ �� T [D I��-�`� � � r' <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> [ Buckets bentonite <br /> Depth to water Bags sand/gravel io <br /> Mix Ratios -5 4fOFilter Pack type/size �3 <br /> Installation Method Surge Block: - (y�ffp <br /> Quantity Installed Discussed with geologist: - {y� <br /> Type of method <br /> EH 29 29 <br />