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MONITORING WELL INSTALLATION REPOn f <br /> Date:�� zoo-1 <br /> ,1 CONSTRUCTION <br /> Premise Address: 1a�+ � <br /> l � `/�` G�, Total Depth_ �1 l _( r/ <br /> Q Z7 Screen Length (from) (to) by <br /> Well No.: —Ten Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from)—(to)- <br /> Drilling <br /> from) (to)Drilling rig type <br /> Permit No. �� d Auger O.D. I.D. <br /> Co Stove pipe/christie box (circle one) <br /> Drilling Company: �'✓�` /Cdfd <br /> ,,'gyp <br /> Driller: �/� cas ng <br /> ei M° <br /> ht IW"" <br /> Consultant <br /> Geologist - <br /> ABOVE-GROUND CtiRlSTY-BOX <br /> COMPLETION COMPLETION <br /> SPECIAL PERMIT INFO. \ Ground Surt <br /> Distance to sewer line Or <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - ft• <br /> f <br /> �ft. t- <br /> - a <br /> m <br /> o <br /> SAMPLING dotted <br /> tac�on _ <br /> Holding Temperature <br /> vivsl pack <br /> Method <br /> Screening Method <br /> Tracking Sheet - ( y/ n ) _ <br /> 20 ft. = tL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ytt PUL <br /> p QO <br /> Storage Location Casing type f 1/L 2rck r <br /> Blank JO ft. Screen l0 ft• <br /> Slot size 010 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Z.S Bags sand/graveI <br /> Mix Ratios "g k Filter Pack type/size 3 - <br /> Installation Method Surge Block: - y/ n ) <br /> Quantity Installed i Discussed with geologist: - (y — <br /> Type of method <br /> EH 29 29 <br />