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•MONITORING WELL INSTALLATION REORT <br /> Date:__ CONSTRUCTION <br /> Premise Address: ( , ,_ ,. Total Depth *r <br /> Screen Length (from) -+15- <br /> Well <br /> +5 (to — <br /> Well No.: Filter Pack (from)��(to)�crj' <br /> Bentonite (from) Q_(to) _ <br /> Inspector. h,AAAra Grout (from)_ 4;)- (to)_ 3- <br /> q 0 � Drilling rig type I <br /> Permit No.. Auger O.D. I.D. <br /> Completion • Stove pipe/duistie box (circle one) <br /> Drilling Company: <br /> Driller: ��e tic T_ casing <br /> height <br /> Consultant ( ( 7 <br /> Geologist_ CJL� iL _ <br /> ABCVE-GACUND Ct4itSTY30X <br /> CONFLETION CCMPLETICN <br /> SPECIAL PERMIT Wo. ��Suiaci <br /> Distance to sewer line grout <br /> Domestic well on site - n ) <br /> 11 yes, locatio distance 1-10-- It• <br /> _It. ft. <br /> Va' 0 <br /> — O <br /> SAMPLING = o <br /> to,nci <br /> tocicn — <br /> HoldingTem�erature p�4c <br /> Method,' in LA- „k 942.12,A I = Ptvdpadc <br /> Screening Method = <br /> Tracking Sheet - n ) — <br /> SPOILS <br /> StorageMethod I� F n 1 fi MATERIALS/DEVELOPMENT <br /> Contamination Noted ((Z/n ) !1 <br /> Storage Location_ m.st �� Casing type 2- <br /> Qy <br /> Blank }O ft. Screen-----5---fr. <br /> GSlot size <br /> ROUTING <br /> Bags cement <br /> Buckets bentonite I /a„,(, ,j D <br /> Depth to water Bags sand/gravel 1 <br /> Mix Ratios6Q e o D�t�IoHi SS �c n��. Filter Pack type/size 1A S na nc <br /> Installation Method�T Surge Block: - ( y/moi y <br /> Quantity Installed Discussed with geol gist: - y/ n <br /> EH 2929 ) <br /> Type of method &,V(Q,� <br /> 0. <br />