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MONITORING WELL INSTALLATION REPORT <br /> Date: /0��`1 le(e CONSTRUCTION <br /> Premise Address: T Z? l��t t A" &/ ""(_1 Total Depth <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector. Grout (from) (to) <br /> Drilling rig type <br /> Permit No. �`��� u S Auger O.D. I.D. <br /> Completion- Stove pipe/christie box (circle one) <br /> Drilling Company: <br /> Driller. �T casing <br /> T height <br /> Consultant =�G <br /> Geologist J180YE-GaCUND <br /> CX <br /> CChFLET,�ON COW =Tiil'-8 CMP:_ CN <br /> SPECIAL PERMIT INFO. Ground Surface t <br /> groutDistance to sewer line <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - - ft- <br /> C <br /> - C <br /> SAMPLING slotted <br /> seczan :P — <br /> Holding Temperature — awl pack <br /> Method =_ <br /> Screening Me--hod h <br /> Tracking Sheet - (y/n} __ <br /> ii. = tL <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Location Casing type <br /> Blank fL Screen ft. <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/ n) <br /> Quantity Installed Discussed with geologisr. - (y/n) <br /> Type of method <br /> EH 29 29 <br />