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r <br /> • 4! <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: f� `� CONSTRUCTION <br /> /� ,, Total Depth <br /> Premise Address:-, � �� -_f."'" `�— P <br /> Screen Length (from) (to) <br /> f� Filter Pack (from) (to) <br /> Well No.: Bentonite (from) (Co)(to <br /> Inspector. — Grout (from) (to) <br /> P Drilling rig type <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> casLng <br /> Drillerheight <br /> Consultant Fmjif- `+"� f <br /> Geo - <br /> av�-�acur+� ct�:sr�r-aox <br /> COWPLEMN Caf tOt_mCH <br /> Circvnd 5asfaca <br /> SPECIAL PERMIT INFO- <br /> pra.•t <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) It. <br /> if yes, location and distance - • <br /> _ a <br /> SAMPLING �IoC'Cr 1; <br /> ;acicn <br /> Holding Temperature -t �19t Fawk <br /> Method r Ix' ,. <br /> Screenin;Method � – 54; <br /> Tracking Sheet y n <br /> it. <br /> SPOILS <br /> Storage Method Zh MATEWALS/DEVELQR ENT <br /> Contamination Noted- y ntyp <br /> Storage Location : - Blank Casing-- <br /> `'� ft. Screen–_______i✓< <br /> Slot size <br /> GROUTING Bags cement <br /> f Buckets bentonite <br /> tivater �� 6 5 Bags sand/gravel <br /> Depth to <br /> Filter Pack type/siz <br /> Mix Ratios e <br /> Zlnstalladan Method Surge Block: - (y/n ) <br /> Quantity Installed Discussed with geologist: - {y/ n) <br /> Type of nctliod <br /> EH 29 29. . <br />