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MONITORING WELL INSTALLATION REPORT <br /> Date: ,/D`qq ss CONSTRUC ION <br /> Premise Address: pOD Total Depth <br /> UA J Screen Length (from) %L (ro) "G' <br /> Well No.: r "V Filter Pack (from) (to) <br /> Bentonite (from) VCY (to) <br /> Inspector, (V /�. ' Grout (fro -9 L (to <br /> Drilling rig type 4tfT <br /> Permit No. Auger O.D. Ile I.D. "I.0 <br /> Completion - Stove pipe/clu-istie box (circle one) <br /> Drilling Company: <br /> r <br /> Driller: casing <br /> /1 height <br /> Consultant 71FIL <br /> T <br /> Geologist -' T <br /> A80VE-GRCUND STY20X <br /> COMPLETION COMPLEIICN <br /> SPECIAL PERMIT INFO. Ground Suixs <br /> Distance to sewer line grout <br /> Domestic well on site - (y/ n) L ft. <br /> If yes, location and distance - ft. <br /> �0 tt <br /> SAMPLING r�L (i slorai <br /> socicn —_ <br /> Holding Temperature = b*a F <br /> Method >_ _ <br /> Screening Method — <br /> Tracking Shcet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) Casing type t.� IP(I / sck ((U <br /> Storage Location Blank SD ft. Screen —K <br /> Slot size d b;�-O <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water S9 . S44. Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> installation Method geologist: <br /> Surge Block: - /0 <br /> Discussed with geologist: - l�yj/ n <br /> Quantity Installed ) <br /> Type of method <br /> EH 2929 <br />