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MONITORING WELL INSTALLATION REPORT <br /> Date: I `�3 CONSTRUCTION <br /> Premise Address: 7 N " t Total Depth <br /> Screen Length (from) (to) <br /> Well No.: fel� `k S Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. �� �� Grout.Drilling rig type (co) <br /> e <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company <br /> casing <br /> Driller:' - = F height <br /> I <br /> Consultant ` <br /> Geologist ABOVE-GRCUND ;�yK30X <br /> COWLETION MAPLEMN <br /> Crd Sutaet <br /> SPECIAL PERMIT INFO. <br /> prat <br /> Distance to sewer line �it. <br /> Domestic well on site - (y/ n) tt <br /> If yes, location and distance - R <br /> O <br /> �• p <br /> C <br /> O <br /> SAMPLING alorai <br /> xecicn <br /> Holding Tem er e 4 C/ <br /> Method R PpKl <br /> Screening Methods <br /> Tracking Sheet - (QP/ n) <br /> tt. <br /> SPOILS <br /> f� _ MATERTAi CfpEVELOPMENT <br /> Storage Method A�"7 W ` ' " ^ <br /> Contamination Note - (Y/ n) Casing type <br /> Storage Location Bl ft Screen —f <br /> Slot size <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water 1b Filter Pack type/size <br /> Mix Ratios Surge Block: - (y/n) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity installed Type of method <br /> EH 29 29 <br />