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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from)'- Q_(to)_� <br /> Well No.: OW-3 Filter Pack (from) <br /> ,\l l/ Bentonite (from) —(to) <br /> Inspector: 1� ltiL ►-� Grout <br /> (from) _(to) R- <br /> 3 <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: <br /> Completion - Stove pipe/christie box (circle one) <br /> � /��,c.,� <br /> Driller:_ casing <br /> height <br /> Consultant_ M e- <br /> Geologist C)'►eo• `o <br /> ABOVE-GROUND <br /> COMPLETION CHRLM-Sox <br /> SPECIAL PERMIT INFO. Ground Surf act .. COMPLETION <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - (y <br /> If yes, location and di ce - - ft. <br /> N eft. <br /> — m <br /> b <br /> C <br /> SAMPLING = <br /> Slotted — <br /> tacton — <br /> Holding Temperature oy-, 1�� <br /> Method <br /> Screening Method //D _ <br /> Tracking Sheet n ) — <br /> 53 S-3- <br /> SPOILS <br /> Storage Method _5 S� MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( / n ) <br /> Storage Location rM SI 6 Casing type Z 11W <br /> Blank �L0 ft. Screen <br /> Slot size I o z 0 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water S Bags sand/gravel <br /> Mix Ratios Filter Pack type/size t*- <br /> Installation Method !]:iAA^A .�,uJ/' Surge Block: - ( y/ n ) <br /> Quantity Installed Discussed with geologist: (y/ z ) <br /> Type of method <br /> EH 29 29 <br /> r _ '� <br />