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MONITORING WELL INSTALLATION REPORT <br /> Date:-2jl `�' ZOI °1 CONSTRUCTION <br /> Premise Address: Total Depth 3 <br /> Screen Length (fro (co) <br /> p Filter Pack (from) (toy <br /> Well No.: <br /> GJ��^- - Bentonite (from)_/j Cto)? <br /> Inspector. Grout (from)If (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company:�M <br /> �p/-- casing <br /> Driller: height <br /> Consultant <br /> Geologist ABOVE-GrICUND <br /> COMPL,F 1 fON CY30X <br /> COMPLC+APLETION <br /> SPECIAL PERMIT INFO. 'rte Ground S��s + _� <br /> prccrt <br /> Distance to sewer line (A <br /> Domestic well on site - (y/ n) ft. <br /> If yes, location and distance - tt <br /> ^ C <br /> O <br /> donna � <br /> SAMPLING sedcn <br /> Holding Temperature <br /> Method <br /> Screening Method = _ <br /> Tracking Shcet - (y/ n) r' <br /> ft. <br /> SPOILS <br /> MATERIALS/DEVELOPMENT <br /> Storage Method ���,f <br /> Contamination Noted- (y/ n) Casing type 2� I/&, 1 --` — <br /> storage Location Blank ft. Screen —ft. <br /> Slot siz <br /> Bags cement <br /> GROUTING Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water Filter Pack type/siz <br /> Mix Ratios Surge Block: - (y t ) <br /> Installation Method Discussed with geologist: - (y/ n) <br /> Quantity installed Type of method <br /> EH 29 29 <br /> o2�RAv� (/ �� 2__ <br />