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MONITORING WELL INSTALLATION REPORT <br /> i <br /> Date: Z - 'J ' << CONSTRUCTION <br /> Premise Address: "k(" Total Depth (01 <br /> a� Screen Length (from) (to)_ <br /> Well No.: 5�` Filter Pack (from) I (to) �Z o" <br /> Bentonite (from) 5Z.-5' (to) <br /> Inspector: (2(l Grout (from) ' (to) U <br /> Drilling rig type <br /> Permit No. GC2-522 Auger O.D. 5. It I.D. <br /> Pn Completion(- ovepi christie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> �T height <br /> Consultant 11 <br /> Geologist alt�' jLjtlt� 7//, <br /> ABOVE-GRMNO <br /> CCMPIEf lON CNAtSTY-80X <br /> COMPLETICN <br /> SPECIAL PERMIT INFO. Carourd Surface ��•� <br /> Distance to sewer line <br /> grout <br /> Domestic well on site - ( / n ) ft. <br /> If yes, location and distan <br /> ft. <br /> ft. <br /> SAMPLING = –° <br /> auction — <br /> Holding Temperature _ F <br /> Method _ <br /> Screening Method jc _ <br /> Tracking Sheet - ( y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y On <br /> Storage Location Casing type <br /> Blank 1i ft. Screen /0 ft. <br /> Slot size Z <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bags sand/gravel <br /> Mix Ratios Filter Pack type/size 'J <br /> Installation Method Surge Block: - qny/ n ) <br /> Quantity Installed Discussed with eologist: -A/ n ) <br /> Type of method <br /> EH 29 29 ZZ,e <br /> rk& - D <br />