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\ice y <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: /Z7/0)U/U CONSTRUCTION <br /> Premise Address'MdTotal Depth <br /> Screen Length (from) (to) <br /> Well No.: h4W Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: ! ( Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/chnstie box (circle one) <br /> Drilling Company: <br /> Driller casing <br /> Consultant �" � jF7LT height <br /> Geologist _ —qv <br /> ABOVEGROUND <br /> COMPLETION CHRZ7Y4BOX <br /> CCMPLE'nCN <br /> SPECIAL PERMIT INFO. Ground Surfers <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - n' <br /> n. <br /> n. <br /> 0 <br /> — e <br /> SAMPLING <br /> Slotted <br /> Holding Temperature 7 <br /> Method D — v'vW Pack <br /> Screening MethodW. O <br /> Tracking Sheet - (Y,/15 <br /> SPOILS <br /> Storage Method ! '" ( MATERIALS/DEVELOPMENT <br /> Contamination Noted - ( y/ <br /> Storage Location Casing type <br /> Blank ft. Screen h. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> Installation Meth Surge Block: - ( y/ n ) <br /> Quantity Instal Discussed Discussed with geologist: - ( y/ n ) <br /> / Type of method <br /> EH 29 29 <br />