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MONITORING WELL INSTALLATION REPORT <br /> Date: /04/0-7 CONSTRUCTION <br /> /��� " 2 in / <br /> PremiseAddress�� C(u{ Total Depth- <br /> �/ 2 1 f Screen Length (from) (to) <br /> Well No.: W f i L Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. �,�2C (� Grout (from (to) <br /> �/ Drilling rig type <br /> Permit No. f 2-I S Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle ane) <br /> Drilling Company: <br /> Driller: axing. <br /> �� - I � e_ght <br /> Consultant `� .�• <br /> at,Geologist ..• � T <br /> !°OVE-GF1 UN <br /> COWLETION C}-ni 711 -Box <br /> SPECIAL PERMIT INFO. '' �_4cursf Suian CCN,{Pl_=ICN <br /> Distance to sewer line ora <br /> Domestic well on site- (y/n ) It <br /> If yes, location and distance - <br /> R. <br /> tt. <br /> v` o <br /> SAMPLING �� � a- bG• P r <br /> C <br /> 'cn — <br /> Holding Temperature _ <br /> Method <br /> Screening Method ,a — <br /> :. <br /> Tracking Sheet - (y/ n ) - — <br /> tt. = Tt. <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted • (y/ n ) <br /> Storage Location Casing type <br /> Blank Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonire <br /> Depth to water_ 11 Bags sand/gravel <br /> Mix Ratios Filter Pack type/s' e <br /> 4pstallation Method - Surge Block: - ( / n ) <br /> Quantity Installed_ Discussed with eologist: - ( y/ n ) <br /> Type of metho <br /> EH 29 29. . <br />