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MONITORING WELL INSTALLATION REPOr,f <br /> Date: �S Fx� CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from) (Q 0 (to) v <br /> Well No.: Filter Pack (from) 6 U <br /> (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) d <br /> Q Drilling rig type <br /> Permit No. U Auger O.D. 252- .I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist r�/ •- T <br /> ABOVE-GROUND <br /> COMPLETION CHR STY-Bax <br /> O <br /> SPECIAL PERMIT INFO. Ground Surface <br /> Distance to sewer line r flf0ul <br /> Domestic well on site (ybn ) <br /> If yes, location and distance - ft' <br /> — a <br /> _ - m <br /> — o <br /> = m <br /> _ <br /> SAMPLING slatted <br /> N A <br /> Holding Temperature /T <br /> Method = VI�Pack <br /> Screening Method —_ <br /> C. <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method s� P) MATERIALS/QEVELOPME NT <br /> Contamination Noted - (y ) rt, n Ve Q ih <br /> Storage Location C/'�n Casing 1e —� r <br /> Blank � ft. Screen�f K <br /> Slot size <br /> GROUTING Bags cement <br /> ' Buckets bentonite <br /> Depth to water -��li Bags sand/gravel <br /> Mix Ratios �v d�^�► Filter Pack type/size <br /> Installation Method `"' Surge Block: - ( / n <br /> Quantity Installed �5�4' Discussed with geo o 'st: - (y� <br /> Type of method <br /> EH 29 29 <br />