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MONITORING WELL INSTALLATION REPORT <br /> Date: y CONSTRUCTION <br /> Premise Address: 7072 Xos,<�17�r Total Depth <br /> Screen Length (from) (to) <br /> Well No.: �tJ Filter Pack (from) 1-17 (to)—_ <br /> 4,ek Bentonite (from) 112.2 (to) <br /> Inspector: l Grout (from) I/ % (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> /V4- <br /> Drilling Company: S Completion - Stove pipe/christie box (circle one) <br /> CJS <br /> Driller: casing <br /> G Nr' height <br /> l9 <br /> Consultant ' <br /> Geologist y fgN CQI}w�2 .3 �► <br /> 7 <br /> ABOVE-GROUND <br /> OOWPLEf ION CHRISTY-BOX <br /> SPECIAL PERMIT INFO. C3roC�PLE'MN <br /> und Surface <br /> Distance to sewer line grout <br /> Domestic well on site - (y/n ) !fir <br /> If yes, location and distance - ft. <br /> ft. ft. <br /> = m <br /> = m <br /> SAMPLING — o <br /> slotted — c <br /> aac5on — <br /> Holding Temperature <br /> Method — gzye�pa <br /> Screening Method — <br /> Tracking Sheet - (y/n) — <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n ) <br /> Storage Location Casing type -2- Pile- <br /> Blank (d ft. Screen ft. <br /> Slot size Z.OAI <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel z <br /> Mix Ratios Filter Pack type/size <br /> Installation Method Surge Block: - (y/n ) <br /> Quantity Installed Discussed with geologist: - (y/ n ) <br /> EH 29 29 Type of method <br />