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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION �[ <br /> Premise Address:&off'/U ��li Z✓n1 � - S ItUv Total Depth l�i <br /> Screen Length (from)' S (to) S <br /> Well No.: Filter Pack (from) (to) _ <br /> B entonite' (from) (to) •�c f <br /> Inspector: Grout (from) .S (to) <br /> Drilling rig type µ <br /> Permit No. Auger O.D. ;i 4,-7') <br /> Drilling Company: <br /> Completion- Stove pipe circle one) <br /> x}11 (.�tail Christie box ( <br /> Driller: casing <br /> height <br /> Consultant_ <br /> Geologist <br /> ABOVE-GRO(JND <br /> COWF LET{O N G�IA IS?Y-80X <br /> COMPLETION <br /> SPECIAL PERMIT INFO, Ground Sur13cs <br /> Distance to sewer line—_" grout <br /> Domestic well on site - (y 4Yft- <br /> If yes, location and distance - ft- <br /> ft. <br /> r <br /> SAMPLING <br /> a*<*n <br /> Holding Temperature = "vDl 1 <br /> ack <br /> Method _ <br /> Screening Method = <br /> Tracking Sheet - (y/n) - <br /> ft. <br /> SPOILS o <br /> Storage Method J C�) MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location S( � Casing type Pvc 5'j, YO <br /> Blank ft. Screen .10 ft. <br /> Slot size U LfJ <br /> GROUTING Bags cement <br /> Buckets bentonite' a ° •ck.4 <br /> Depth to water 2 Bags sand/gravel <br /> Mix Ratios_ '-1-6 Filter Pack type ize <br /> Installation Method _____ <br /> -._Surge_Block: - ..y-—n-) — <br /> Quantity Installed Discussed with ologist: - (y/ n ) <br /> EH 29 29 Type of method <br />