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MONITORING WELL INSTALLATION REPIART <br /> Date:_ �/ 0; <br /> CONSTRUCTION <br /> Premise Address: /z /�j ,44r-- <br /> Total Depth <br /> Well No.: AI, btl /, Z `,/ Screen Length (from) (to) <br /> Filter Pack (from) (to)-- <br /> Inspector: � Bentonite (from) (to) <br /> Grout (from) (to)— <br /> Permit No. Drilling rig type <br /> Auger O.D. I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/christie box (circle one) <br /> Driller: <br /> casing <br /> Consultantheight�a_� <br /> Geologist <br /> AE&E-GROUND <br /> COMPLETION CHR*TY-80X <br /> SPECIAL PERMIT INFO. G=nd Swixa COMPLETION <br /> Distance to sewer line QroL[t <br /> Domestic well on site - ( y/ n) <br /> If yes, location and distance - <br /> �ft. ft. <br /> .hv � <br /> SAMPLING = <br /> slotted v — <br /> &sction <' — <br /> Holding Temperature <br /> Method =° = 9""°I P <br /> — <br /> Screening Method }: — <br /> Tracking Sheet - (y/ n ) " <br /> 77JJAA,, .k _ <br /> ZV t �_ <br /> � � ft. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n) <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 <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 />