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MONITORING WELL INSTAL LikTION REPORT <br /> Date:3/ 0 CONSTRUCTION <br /> Premise Address: /Y6? 6 &!2�4oj- Total Depth <br /> / d ' "&Screen Length (from) (to) <br /> Well No.• AL, Mw- Filter <br /> Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> •� Completion - Stove pipe/cluistie box (circle one) <br /> Drilling Company: <br /> Driller: " �'" caging <br /> y he,ght <br /> Consultant <br /> Geologist ABOVE-GRCUND <br /> COhrfi'L.ETION GI�tSTY-30X <br /> cOMPc EMN <br /> SPECIAL PERMIT INFO. W 7rd Sviacs <br /> Qroct <br /> Distance to sewer line ' <br /> Domestic well on site - (y/ n) �S 4 <br /> If yes, location and distance - <br /> .Y 0 <br /> 7" M <br /> Q <br /> SAMPLING ['1� C�'�''• Iarni :i <br /> sacicn "• <br /> Holding Temperature Pack <br /> Method PIP = _ <br /> Screening Method <br /> Tracking Sheet - (y/n) `- <br /> �0 — <br /> SPOILS <br /> Storage Method a� ' MATERIALS EVELOPMENT <br /> Contarnination Noted- (y/ ) <br /> Casing type <br /> Storage Location <br /> Blank fG Screen_----.ft. <br /> Slot size 0.0?,0 <br /> GROUTING r Bags cement <br /> J Buckets bentonite <br /> Depth to water �� Bags sand/gravel <br /> Mix Ratios Filter Pack typery <br /> 'ze <br /> installation Metho Surge Block: - ` n) <br /> Quantity Installed Discussed with geologist: - q// n ) <br /> Type of method <br /> EH 29 29 <br />