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i • <br /> MONITORING WELL INSTALLATION REPORT <br /> Date: zI / y) CONSTRUCTION <br /> Premise Address: f4. Total Depth / 0 1 <br /> Screen Length (from) (to) <br /> Well No.: MW Filter Pack (from) (to) <br /> `1/� Bentonite (from) (to)Inspector: t4 Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Completion - Stove pipe/christie box (circle one) <br /> Drilling Company: � (� <br /> Driller: ' {D�-I heighgI F17 <br /> Consultant �S - <br /> Geologist A80VE-GFICUND <br /> COh�FLErION COMPL MON <br /> II_ '�� COt�4PL_�TICN <br /> SPECIAL PERMIT INFO. " Grourd Swacs <br /> Distance to sewer line 1` �� � green <br /> Domestic well on site - (y/ n) S J ft. <br /> If yes, location and distance - ft. <br /> SrJ►�.+� ft. � <br /> ;. m <br /> O <br /> SAMPLING <br /> l0 sotcicn —_ <br /> Holding Temperature = <br /> _ Gr+v�i F.acic <br /> Method _— <br /> ii <br /> Screening Method _ <br /> Tracking Sheet - (y/ n ) <br /> SPOILS T� <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/ n ) y P d U < � �D <br /> Storage Location _ Casing type — <br /> Blank ft. Screen K• <br /> Slot size_ 0 .010 <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water "`� Bags sand/gravel <br /> Mix Ratios '&Y1T Filter Pack type/size Z I-L' — <br /> Installation Method Surge Block: - (y/n ) <br /> Quantity Installed Discussed with geologist: -0Y n ) <br /> Type of method ��// <br /> EH 29 29 <br />