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�—R ONITORING WELL INSTALLATION REPCItt <br /> Date: J 3 CONSTRUCTION <br /> Premise Address: 102 .S 4!,)l a Total Depth <br /> Screen Length (from) 7& (to) <br /> Well No.: �/ Filter Pack (from) G e (to) �U <br /> �/G /� Bentonite (from) (to) <br /> Inspector: /v < Grout (from) S- f (to) <br /> QO 32 3o2U Drilling rig type Cµe <br /> Permit No. Auger O.D. gk I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: �im�/vl °�V --ii�� casing <br /> T height <br /> Consultant <br /> Geologist <br /> ABOVEGROUND CHMM-Box <br /> COMPLETION COMPLEnCN <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) �_n <br /> If yes, location and distance - <br /> n. <br /> n. <br /> = m <br /> — o <br /> _ <br /> 0 <br /> SAMPLING cloned <br /> sao9on <br /> Holding Temperature = q P <br /> Method <br /> Screening Method Z` <br /> Tracking Sheet - (y/ n ) <br /> n. = n. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type �7V L <br /> Blank 7u ft. Screen_.Zj� ft. <br /> Slot size 0 Z o <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - ((}/ n ) <br /> Quantity Installed Discussed with geologist: - (y/n ) <br /> Type of method `Yr[ol,r <br /> EH 29 29 <br />