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ONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address:- <br /> ,/a a (.�'A-A lid Total Depth <br /> Well No.: ji l Cj� Screen Length (from) -50 (to) 36 <br /> Filter Pack (from) S`D i (to) a <br /> Bentonite (from) ;'2 (to) a <br /> Inspector: (YL � p �� Pmt r ! Grout (from) aC, ` (to)� � <br /> Permit No. <br /> Drilling rig type a 1 o r s 5 f a oil <br /> Auger O.D. / I.D. <br /> Drilling Company:_P� 1�� J — <br /> Completion - Stove pip chriSttee (circle one) <br /> l l �� ��,�vtiyy�„s� <br /> Driller: casing <br /> Consultant A7 height <br /> LIZA -qVT <br /> ABOVE-GROUND <br /> COMPLETION C}-Sim-BOX <br /> SPECIAL PERMIT INFO. GroundSurface COMPLETION <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft. <br /> .30 a. ft. <br /> ft <br /> q <br /> SAMPLING = o <br /> Clotted — c <br /> &*cion = <br /> Holding Temperature <br /> Method grwW Pack <br /> Screening Method Mi, I'1`\ — <br /> Tracking Sheet - (y/n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y n " <br /> Storage Location Casing type <br /> Blank 3 t� ft. Screen <br /> Slot size ,0 D, <br /> GROUTING Bags cement <br /> 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 /> EH 29 29 Type of method <br />