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MONITORING WELL INSTALLATION REPORT' <br /> �I C i y CONSTRUCTION <br /> Date: / 1 <br /> I �. ( ^SC Total Depth (ro) m - <br /> Premise Address: Screen Length (frem) =+-%: — <br /> Filter Pack (from) 1:3/ (to) 01 <br /> Well No.: rn �� - Bentonite (from) 01W (to) $� <br /> AGrout (from) //• (to) <br /> Inspector. Drilling rig We /fid I <br /> Auger O.D. I.D. <br /> Permit No. Completion - Stove pipe/ tle bo (circle one) <br /> Drilling Company: lI —i- vti <br /> p �� casing <br /> Driller: �� ^'� `-���— height <br /> Consultan � <br /> Geologist a r2fi ABOVE-GSCJJND C4-RtSTY-Box <br /> CONVLEi ON CCMPL=-M0N <br /> Cinwnd Sufis <br /> SPECIAL PERMIT INFO. <br /> grout <br /> Distance to sewer line ft. <br /> —EWT <br /> Domestic well on site - (y/ n) <br /> If yes, location and distance - ti. <br /> 1 V 0 <br /> O <br /> C <br /> „_" GS doted <br /> SAMPLING <br /> . " soden _ <br /> Holding Temperature _ ¢"9I F <br /> ack <br /> Method <br /> Screening Method _ <br /> Tracking Sheet - (y/ n) <br /> tt. tt. <br /> SPOILS <br /> Storage Method 55 Gy MATERIA[S/DEVELOPMEN C <br /> Contamination Noted - (y/n) Casing type a/r -) V <br /> Storage Location — Blank -O-O K, Screen I G` h• <br /> a 1 T Slot siz <br /> Bags cement <br /> e <br /> GROUNGv, � t G^� �CI)� 13� <br /> TI <br /> Buckets bentonite <br /> Bags sand/gravel <br /> Depth to water ti f Filter Pack type/size <br /> Mix Ratios <br /> Surge Block: - geologist: <br /> / n <br /> Installation Method ) <br /> Quantity installed Discussed with geologist: - (y/ n ) <br /> Type of method <br /> EH 29 29 <br />