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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUC'T'ION <br /> Premise Address: Total Depth 0'7_� 96 K6S � rSd <br /> Screen Length (from) (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Zf�� � Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/cliristie box (circle one) <br /> Drilling Company: <br /> Driller: casing <br /> he; <br /> Consultant PYA ` <br /> Geologist `3 ��- "' <br /> IIBCVE-GR CUND CI~RSTY-BOX <br /> CO tri LE'r C N CCt+APtLEMCN <br /> SPECIAL PERMIT INFO. Ground Stsixs <br /> Distance to sewer line aroc t <br /> Domestic well on site - (y/ n ) <br /> If yes, location and distance - n, <br /> ft. <br /> M <br /> C <br /> SAMPLING •lorc.i � _ <br /> tacicn <br /> Holding Temperature = <br /> (�'1Y9!FcY.X <br /> Method = <br /> Screening Method <br /> Tracking Sheet - (y/ n ) <br /> SPOILS <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) <br /> Storage Locarion Casing type <br /> Blank fr- Screen h• <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 geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />