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MONITORING WELL INS'T'ALLATION REPORT <br /> v 3� 3 CONSTRUCTION <br /> Date: N-r <br /> Premise Address: )_b E SZV Total, Depth <br /> Screen Length (from) {to) <br /> Well No.: t Arfxt Filter Pack (from) (to) <br /> Bentonite (from) (to) <br /> Inspector: . Grout (froth) (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: casing <br /> height <br /> Consultant <br /> • <br /> Geologist � T <br /> ABOVE-GRCUND <br /> COWLEMN GZ�ItSTY-30X <br /> co�c...mcc� <br /> SPECIAL PERMIT INFO. Grcurd Stxf�ct <br /> great <br /> Distance to sewer line <br /> rMl <br /> Domestic well on site - (y/n) tt. <br /> If yes, location and distance - ft. <br /> 4 <br /> SAMPLING Z <br /> todcn _ <br /> Holding Temperature — F <br /> Method Z:* <br /> Screening Method <br /> Tracking Shcet (y/ n) <br /> SPOILS �, r <br /> Storage Method <br /> MATERIALS/DEVELOPMENT <br /> Contamination Noted- {y/ n) 3PSL <br /> Storage Location Casing type <br /> BIank ft. Screen <br /> Slot size <br /> GROUTING '` y Bags cement <br /> V QQ Buckets bentonite <br /> Depth to water j �� Bags sand/gravel <br /> Mix Ratios Filter Pack type/size <br /> installation Method Surge Block: - ( y/n ) <br /> Quantity Installed Discussed vrith geologist: - (y/ n) <br /> Type of method <br /> EH 29 29 <br />