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MONITORING WELL INSTALLA'T'ION REPORT <br /> Date: CONSTRUCTION <br /> _ r <br /> Premise Address: �� � '� Total Depth io <br /> Screen Length (from) C o (to) Y <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) 3V1 (to) - <br /> Inspector. Grout (from) ' (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. -,)-61/ I.D. V, <br /> Completion - Stove pipe/ iristie box (circle one) <br /> Drilling Company: 10 ' + d:2 <br /> Drill rZ casing <br /> he,, <br /> Consultant r717L <br /> 7F <br /> Geologist J� ` AEFCV -GFICl1NO <br /> i COfvg'��TiON CNASSiY-BOX <br /> COMPL_ZTICN <br /> SPECIAL PERMIT INFO. G=nd Statact_-- ---_ <br /> Z5-'n grout <br /> Distance to sewer line <br /> Domestic well on site - (y/ n ) ,, �a'— a ✓�YaS� s ft. <br /> If yes, location and distance - , ft. <br /> >. o <br /> Q <br /> SAMPLING tbrai <br /> xec=n '— <br /> Holding Temper tune <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - ( y/ n ) <br /> n. <br /> SPOILS <br /> Storage Method f� o� — IdtATERIALS/DEVEI.OPMENT <br /> Contamination Noted - ( y/ n li <br /> Storage Location Casing type <br /> Blank ft. Scre n qU fr• <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 Method ' �� Surge Block: - ( y/ ) <br /> Quantity Installed Discussed with geologist: - (_y inn ) <br /> Type of method <br />