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MONITORING WELL INSTALLATION REPORT <br /> Date: ' /A( 6 CONSTRUCTION <br /> i <br /> Premise Address:/lb c Total Depth �7n <br /> / ' Screen Length (from) (to) _ <br /> Well No.: �(,/ Filter Pack (from) o (to) <br /> V Bentonite (from) 43 (to) o <br /> Inspector. 7�nn. C ( Grout (from) i-fi (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company <br /> : casing <br /> Driller <br /> -_ height <br /> Consultant <br /> Geologist A - <br /> A80VE-GRCUND CNRiSTY-80X <br /> 00MPLEr1CN OOMPLETION <br /> SPECIAL PERMIT INFO. <br /> prat <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) 1/1 ft. <br /> If yes, location and distance - ft. <br /> 36S <br /> = o <br /> SAMPLING slored <br /> sacicn —_ <br /> Holding Temperature = graystPack <br /> Method ri <br /> Screening Method r = <br /> Tracking Sheet - (y/ n) <br /> 6° a. = n. <br /> SPOILS 1%6 <br /> Storage Method IY� m0 a'atl- MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/67) el. <br /> Storage Location Casing e Zf r�'C-1 <br /> Blank _fc. Screen h• <br /> Slot size PJ• 02-0 <br /> GROUTING Bags cement I <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel X <br /> Mix Ratios Filter Pack type/size(I <br /> Installation Method Surge Block: - ( y ) <br /> Quantity Installed Discussed with geol gist: - 0/ n ) <br /> Type of method tal - <br /> EH 29 29 <br />