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MONITORING WELL INSTALLATION REPOi%f <br /> Date: T'��' CONSTRUCTION <br /> Premise Address: �&' 'A�7— Total Depth <br /> �� Screen Length (from) (to) <br /> Well No.: -7A%riv /5 Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. U/�—' Auger O.D. I.D. <br /> Oe Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: �" Z- casing <br /> height <br /> Consultant <br /> Geologist AgpyE-GROUND <br /> COWPLET;CN t,tiA1P ETIC <br /> Pt c <br /> SPECIAL PERMIT INFO. Ground Surface <br /> ? grout <br /> Distance to sewer line <br /> Domestic well on site - (y ft. <br /> If yes, location and distance - ft. <br /> ft. <br /> C <br /> SAMPLING sloes "' _ C <br /> &*don <br /> Holding Temperature gmvw Pack <br /> Method =_ <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 <br /> Blank ft. Screen /D fr• <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 />