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MONITORING WELL INSTALLATION REPORT-� <br /> rr CONSTRUCTION <br /> Date: 3f <br /> M� �tG1 Total Depth �0 <br /> Premise Address: J Screen Length {from) a (to) w <br /> Well No.: � ' �f S wS Filter Pack (from) <br /> Bentonite (from) <br /> Inspector. Grout (fro (to) <br /> Drilling rig type 4 <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/clzristie box (circle one) <br /> Drilling Company: <br /> casing <br /> Driller: UMC F he_9ht: <br /> Consultant ' <br /> Geologist C s AiOVE-GRCUND C}�ttSTY-BOX <br /> o0NFLE 4N cGMPLEMON <br /> Ground SLx1acs <br /> SPECIAL PERMIT INFO. <br /> gran <br /> Distance to sewer line <br /> Domestic well on site - (y/ n) 5 6 <br /> IE yes, location and distance - •'�"" ft' <br /> N.. <br /> fn � <br /> CFS�/Rv e�o/ iEor.�i :•,': � <br /> SAMPLING �nvig Pack <br /> soricn "� <br /> Holding Temperature <br /> Methodt <br /> Screening Method Y <br /> _ <br /> Tracking Sheet - / n ) -` <br /> tt. _...�.,. <br /> SPOILS <br /> Storage Method AA& MATERIALS/DEVELOPMENT <br /> Contamination Noted - { / ) Casing type_k�� WP 1_ <br /> Storage Location Blank ft. Screen_32__. <br /> Slot size 4 <br /> GROU'ITNG Bags cement <br /> Buckets bentonite <br /> SS Bags sand/gravel �� --- <br /> Depth to water, Filter Pack type/size <br /> Mix Ratios Surge Block: - (I VY n ] <br /> Installation Method Discussed with geologist: - ( n) <br /> Quantity installed R, Type of method <br /> EH 29 29. <br />